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.
Email address *
What kinds of services are you looking for?
Name of LME MCO, if Known
Name of LME MCO Care Coordinator, if Known
LME MCO Care Coordinator
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.
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This form was created inside of Community Based Care.