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. This iframe contains the logic required to handle Ajax powered Gravity Forms. PDF Form to Fill and Mail