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
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This form was created inside of Community Based Care.