Referral Form (formerly Broadstep/Coastal Southeastern United Care)

Referral Form (formerly Broadstep/Coastal Southeastern United Care)
Referral Source Information
Referral Source Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Client Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Type

Medicaid (e.g., Alliance, Eastpoint, Trillum, Vaya)Commerical Insurance (e.g., Blue Cross Blue Shield, Cigna, Humana, Tricare)Self PayOther
Policy Number
Does the client have a legal guardian?

YesNo
Parent/Guardian Name (if applicable)

First NameLast Name
Parent/Guardian Phone
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Previous / Current MH / SA Provider Name
Reason for Referral
Select all that apply

DepressionAngerAnxietyADHDTraumaSuicidalPsychosisOppositional DefianceSubstance AbuseOther
SERVICES NEEDED

If known
Select all that apply

Clinical AssessmentPsychiatric EvaluationMedication ManagementOutpatient TherapyACTT ServicesIntensive In-HomePeer Support ServicesCommunity Support TeamOther
Additional Questions? Please reach our Admissions Team at (910) 769-5851.

North Carolina Counties Served

Bladen • Brunswick • Carteret • Cleveland • Columbus • Craven • Gaston
Lincoln • New Hanover • Onslow • Pamlico • Pender • Robeson • Scotland

North Carolina Office Locations

Gastonia • Lumberton • Jacksonville • Supply • Wilmington
Should be Empty:

Referral Form (formerly Broadstep/Coastal Southeastern United Care)

Referral Source Information

Client Information

Reason for Referral

SERVICES NEEDED