Refer

New Services Request
Please check service and fill out all information*
- Community Navigator
- EOR Training
- My FIRST Key, Supported Living
- Outpatient Therapy
- PLAY Project
- Special Education Navigation
- Specialized Consultative Services (Waiver Service)
- ABA Services
Today's Date*

Today's Date
Have you talked to someone at FIRST about this referral?*
- Yes
- No
If so who?
Individual/Child’s Name:*
First Last
Date of Birth:*
Sex:*
- Male
- Female
- Other
Race:*
Legal Guardian/Parent(s) Name:*
First Last
Address:*
Street Address Address Line 2 City State ZIP Code
Legal Guardian/Parent(s) Email:*
Legal Guardian/Parent(s) Phone:*
Other contact:
Phone:
Person/Agency Referring:
Phone:
Email:
Community Program/School/Childcare Center*
Please tell us what community program, school or childcare center the person attends
Receiving Services:*
Please describe the reason for the referral*
Select Option*
- Please contact us to talk about ways FIRST can support my/our needs.
- Please contact my care coordinator to discuss.
*
- I understand that this consent is voluntary and is valid until the party withdraws this consent, in writing/verbally, at any time. I understand that there are statutes and regulations protecting the confidentiality of authorized information. I also understand that in order to receive appropriate treatment that information may be shared between treating agencies without consent in accordance with N.C.G.S 122 C-52 through 122 C-57.
*
- I understand that this consent does not guarantee that these services will be provided by FIRST.
Date

New Services Request