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?
Residential/Overnight Services -- Group or Family Setting
Community-Based Waiver Services (NC Innovations, formerly CAP)
Personal Care Services (Lenoir, NC area only)
Early Intervention (0-3) Services (Boone, NC area only)
Psychological Testing (Gastonia, NC area only)
Do you have a preference for a specific NC provider?
No preference -- first available
HomeCare Management Corporation
Hughes Behavioral & MH Services
Lindley Habilitation Services
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
Alternate Time to Call (not required but very helpful)
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