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.
Sign in to Google to save your progress. Learn more
Email *
How did you hear about us?
Clear selection
What kinds of services are you looking for?
Name of LME MCO, if Known
Name of LME MCO Care Coordinator, if Known
Do you have a preference for a specific NC provider?
Clear selection
Name of Person Seeking Services *
Relationship to Person Served *
Preferred Service Location County (if no preference, "Statewide")
Phone Number *
Best Time to Call
Additional Comments
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.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Community Based Care.