North Carolina Referral Form
THIS FORM FOR USE FOR NC REFERRALS ONLY. 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.
What kinds of services are you looking for?
Do you have a preference for a specific NC provider?
Name of Person Seeking Services *
Your answer
Relationship to Person Served *
Preferred Service Location County (if no preference, "Statewide")
Your answer
Phone Number *
Your answer
Best Time to Call *
Your answer
Alternate Time to Call (not required but very helpful)
Your answer
Additional Comments
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Community Based Care.