Refer for Support or Services New Services Request Please let us know what support you are looking for.* General Information, include details in referral Early Intervention for young child with autism Special Education - Parent Education or Support Training or Support for EOR Information or apply for our My FIRST Key, Supported Living Support for your family member with disabilities from our Clinical Team Training or support for a microenterprise If you have an Outpatient Therapy referral go hereToday's Date* MM slash DD slash YYYY Today's Date Have you talked to someone at FIRSTwnc about this referral?* Yes No If so who? Individual/Child’s Name:* First Last Individual's Phone NumberPhysical Address: (Not a PO Box)* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What County does person live in? Individual's Email: Date of Birth:* MM slash DD slash YYYY Gender:* Male Female Other Race:*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 Agency staff or Care Manager)Legally Responsible Person's Email: (Not Agency staff or Care Manager) Parent Name: if different from legally responsible person First Last Parent Phone: if different from legally responsible person (Not Agency staff or Care Manager)Parent Email, if different from Legally Responsible Person' (Not Agency staff or Care Manager) Other contact: Phone:What is the best way to contact you?* Phone Call Email Text Person/Agency Referring: Phone:Person referring Email: Community Program attending* Please tell us what community program the person attends. School attending* Please tell us what school or childcare center the person 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 FIRSTwnc 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 FIRSTwnc. PDF Form to Fill and Mail