ACS Request for Services

Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Are you a referral source or a potential consumer?

Referral SourcePotential ConsumerOther
Are you or the individual being referred experiencing a current crisis that requires immediate attention?

YesNo
We can provide immediate assistance.

Please contact a member of our Mobile Crisis team at 888-315-2880. The Mobile Crisis team is available 24/7 for all crisis needs.

Thank you.
Contact Name

First NameLast Name
Contact E-mail
example@example.com
Contact Phone Number
Location Preference

Cherokee County: 750 US Hwy. 64 West, Murphy, NC 28906Clay County: 254 Church Street, Hayesville, NC 28904Graham: 217 South Main St., Robbinsville, NC 28771Swain: 100 Teptal Terrace, Bryson City, NC 28713Macon: 100 Thomas Heights, Suite 206, Franklin, NC 28734Haywood (The Balsam Center): 91 Timberlane Rd, Waynesville, NC 28786
Agency Name
Agency Type

DSS / DHS / DFS / CPSMCOGroup HomeMedical PracticeTherapy OfficeNon-ProfessionalPsychiatric HospitalPsychiatric PracticeSchoolShelterOther
Referrer Name
Referrer Type

Client/FamilyResidential Family (RTC)Other
Consumer Information

This information is about the individual being referred for services. Please provide as much information as you can. There is also an opportunity to upload a confidential document that may include more information about the individual if desired.
Consumer Name

First NameLast Name
Parent/Legal Guardian Name (if applicable)

First NameLast Name
Consumer Date of Birth

MonthDayYear
Date
Consumer Age
Consumer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consumer or Parent/Guardian Phone Number
Consumer Insurance

Self-PayMedicaidMedicareIPRS (State-Funded)Blue Cross Blue ShieldNC Health ChoiceOther
Reason for Referral
What services are you interesting in receiving?

Mobile CrisisMedication ManagementAdult Recovery UnitGroup Home ConsiderationPsychological TestOutpatient CounselingSubstance Abuse Intensive Outpatient (SAIOP)DWI Assessment/TreatmentCommunity Support TeamIntensive In-HomePeer SupportSupported EmploymentDay TreatmentJail-Based ServicesI am not sure
Please upload any supporting documentation

Cancelof
Additional Comments
Should be Empty:

Consumer Information