Refer for Support or Services New Services Request Please check service and fill out all information. If information is not complete, this referral can not be processed*Community NavigatorEOR TrainingMy FIRST Key, Supported LivingFull Circle - Personal NetworksPLAY ProjectSpecial Education NavigationSpecialized Consultative Services (Innovations required)If you have an Outpatient Therapy referral go hereToday's Date* Date Format: MM slash DD slash YYYY Today's Date Have you talked to someone at FIRST about this referral?* Yes No If so who?Individual/Child’s Name:* First Last Individual's Phone NumberAddress: (NOT PO Box)* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Individual's Email: Date of Birth:* Date Format: MM slash DD slash YYYY Gender:*MaleFemaleOtherRace:*WhiteHispanic or LatinoBlack or African AmericanNative American or American IndianAsian / Pacific IslanderOtherLegally Responsible Person*SelfParent (individual is under 18)Guardian (same as parent)Guardian (other than parent)Who is the legally responsible party. If the person is over 18, there may be a parent and a guardian. FIRST needs information on both in this case. Legally Responsible Person's Name: (ie self, parent or guardian) First Last Legally Responsible Person's Phone, if different from Individual: (NOT QP or Care Manager)Legally Responsible Person's Email: (NOT QP or Care Manager) Parent Name: if different from legally responsible person First Last Parent Phone: if different from legally responsible person (NOT QP or Care Manager)Parent Email, if different from Legally Responsible Person' (NOT QP or Care Manager) Other contact:Phone:Person/Agency Referring:Phone:Person referring Email: Community Program/School/Childcare Center*Please tell us what community program, school or childcare center the person attends. Give the name of school or childcare center, if the individual attends. Receiving Services:*Innovations WaiverIEP at SchoolWaitlist for waiverMental Health ServicesOtherPlease describe the reason for the referral. Please include the member's current address, if different.*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. PDF Form to Fill and Mail