North Carolina Referral Form
THIS FORM FOR USE FOR NC REFERRALS ONLY. If you would like to inquire by phone, please contact our referral line at: 1-866-681-9856, or email:
. Use this form to alert CBC Intake & Referral Specialist of an inquiry for services at any of our family of providers. *Please ensure you scroll to bottom and click the "submit" button.
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How did you hear about us?
LME/MCO Care Coordinator
What kinds of services are you looking for?
Residential/Overnight Services -- Group or Family Setting
Community-Based Waiver Services (NC Innovations, formerly CAP)
B3 Medicaid (Non-Innovations) Community-Based Services
Personal Care Services (Home Health)
Psychological Testing (Gastonia, NC area only)
Name of LME MCO, if Known
Name of LME MCO Care Coordinator, if Known
Do you have a preference for a specific NC provider?
No preference -- first available
HomeCare Management Corporation
Hughes Behavioral & MH Services
Lindley Habilitation Services
Pinnacle Home Care
Name of Person Seeking Services
Relationship to Person Served
Legally Responsible Person (Non-Family Member)
LME MCO Care Coordinator
Dept. of Social Services
Preferred Service Location County (if no preference, "Statewide")
Best Time to Call
If you are an employee of a CBC provider agency, please type in your name below.
A copy of your responses will be emailed to the address you provided.
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