CCAC Referral Interest Form - Carousel Child Advocacy Center

- Step 1 of 3

Thank you for your interest in Clinical/Therapy Services at the Carousel Child Advocacy Center. This form will take approximately 5 minutes to complete. Once completed a member of our Team will contact you within 1-2 business days to discuss the next steps for scheduling an appointment.

If you need to schedule a CHILD MEDICAL EXAM (CME) please contact a family advocate at 910-254-9898 or email franchesca.ramirez@carouselcenter.org to request the CME referral form and staff your case further

Your Name - Full Name of Person Completing this Form (If patient is under 18, you must be the patient's legal guardian). *

First

Middle

Last

What is your relationship with the patient/child? (ex. Mother, Father, DSS worker, Other family member.)

Please select below any custody situations that apply to the patient. (Documentation may be requested).

Legal guardians are divorced
Foster Care/DSS Custody
In the care of a family member or friend
Parenting/custody agreement related to medical decisions
Patient is 18 years or older
Not Applicable
Other

What is the best Phone number for You? (this is how we will contact you to discuss next steps, and for scheduling an appointment.)

United States+1
United Kingdom+44
Afghanistan+93
Albania+355
Algeria+213
American Samoa+1
Andorra+376
Angola+244
Anguilla+1
Antigua & Barbuda+1
Argentina+54
Armenia+374
Aruba+297
Ascension Island+247
Australia+61
Austria+43
Azerbaijan+994
Bahamas+1
Bahrain+973
Bangladesh+880
Barbados+1
Belarus+375
Belgium+32
Belize+501
Benin+229
Bermuda+1
Bhutan+975
Bolivia+591
Bosnia & Herzegovina+387
Botswana+267
Brazil+55
British Indian Ocean Territory+246
British Virgin Islands+1
Brunei+673
Bulgaria+359
Burkina Faso+226
Burundi+257
Cambodia+855
Cameroon+237
Canada+1
Cape Verde+238
Caribbean Netherlands+599
Cayman Islands+1
Central African Republic+236
Chad+235
Chile+56
China+86
Christmas Island+61
Cocos (Keeling) Islands+61
Colombia+57
Comoros+269
Congo - Brazzaville+242
Congo - Kinshasa+243
Cook Islands+682
Costa Rica+506
Croatia+385
Cuba+53
Curaçao+599
Cyprus+357
Czechia+420
Côte d’Ivoire+225
Denmark+45
Djibouti+253
Dominica+1
Dominican Republic+1
Ecuador+593
Egypt+20
El Salvador+503
Equatorial Guinea+240
Eritrea+291
Estonia+372
Eswatini+268
Ethiopia+251
Falkland Islands+500
Faroe Islands+298
Fiji+679
Finland+358
France+33
French Guiana+594
French Polynesia+689
Gabon+241
Gambia+220
Georgia+995
Germany+49
Ghana+233
Gibraltar+350
Greece+30
Greenland+299
Grenada+1
Guadeloupe+590
Guam+1
Guatemala+502
Guernsey+44
Guinea+224
Guinea-Bissau+245
Guyana+592
Haiti+509
Honduras+504
Hong Kong SAR China+852
Hungary+36
Iceland+354
India+91
Indonesia+62
Iran+98
Iraq+964
Ireland+353
Isle of Man+44
Israel+972
Italy+39
Jamaica+1
Japan+81
Jersey+44
Jordan+962
Kazakhstan+7
Kenya+254
Kiribati+686
Kosovo+383
Kuwait+965
Kyrgyzstan+996
Laos+856
Latvia+371
Lebanon+961
Lesotho+266
Liberia+231
Libya+218
Liechtenstein+423
Lithuania+370
Luxembourg+352
Macao SAR China+853
Madagascar+261
Malawi+265
Malaysia+60
Maldives+960
Mali+223
Malta+356
Marshall Islands+692
Martinique+596
Mauritania+222
Mauritius+230
Mayotte+262
Mexico+52
Micronesia+691
Moldova+373
Monaco+377
Mongolia+976
Montenegro+382
Montserrat+1
Morocco+212
Mozambique+258
Myanmar (Burma)+95
Namibia+264
Nauru+674
Nepal+977
Netherlands+31
New Caledonia+687
New Zealand+64
Nicaragua+505
Niger+227
Nigeria+234
Niue+683
Norfolk Island+672
North Korea+850
North Macedonia+389
Northern Mariana Islands+1
Norway+47
Oman+968
Pakistan+92
Palau+680
Palestinian Territories+970
Panama+507
Papua New Guinea+675
Paraguay+595
Peru+51
Philippines+63
Poland+48
Portugal+351
Puerto Rico+1
Qatar+974
Romania+40
Russia+7
Rwanda+250
Réunion+262
Samoa+685
San Marino+378
Saudi Arabia+966
Senegal+221
Serbia+381
Seychelles+248
Sierra Leone+232
Singapore+65
Sint Maarten+1
Slovakia+421
Slovenia+386
Solomon Islands+677
Somalia+252
South Africa+27
South Korea+82
South Sudan+211
Spain+34
Sri Lanka+94
St. Barthélemy+590
St. Helena+290
St. Kitts & Nevis+1
St. Lucia+1
St. Martin+590
St. Pierre & Miquelon+508
St. Vincent & Grenadines+1
Sudan+249
Suriname+597
Svalbard & Jan Mayen+47
Sweden+46
Switzerland+41
Syria+963
São Tomé & Príncipe+239
Taiwan+886
Tajikistan+992
Tanzania+255
Thailand+66
Timor-Leste+670
Togo+228
Tokelau+690
Tonga+676
Trinidad & Tobago+1
Tunisia+216
Turkey+90
Turkmenistan+993
Turks & Caicos Islands+1
Tuvalu+688
U.S. Virgin Islands+1
Uganda+256
Ukraine+380
United Arab Emirates+971
United Kingdom+44
United States+1
Uruguay+598
Uzbekistan+998
Vanuatu+678
Vatican City+39
Venezuela+58
Vietnam+84
Wallis & Futuna+681
Western Sahara+212
Yemen+967
Zambia+260
Zimbabwe+263
Åland Islands+358

What is your Email address? (This will be used to send electronic paperwork/consents, needed for care). *

Name of Legal Guardian (if different from above) *

First

Last

Legal Guardian Phone

United States+1
United Kingdom+44
Afghanistan+93
Albania+355
Algeria+213
American Samoa+1
Andorra+376
Angola+244
Anguilla+1
Antigua & Barbuda+1
Argentina+54
Armenia+374
Aruba+297
Ascension Island+247
Australia+61
Austria+43
Azerbaijan+994
Bahamas+1
Bahrain+973
Bangladesh+880
Barbados+1
Belarus+375
Belgium+32
Belize+501
Benin+229
Bermuda+1
Bhutan+975
Bolivia+591
Bosnia & Herzegovina+387
Botswana+267
Brazil+55
British Indian Ocean Territory+246
British Virgin Islands+1
Brunei+673
Bulgaria+359
Burkina Faso+226
Burundi+257
Cambodia+855
Cameroon+237
Canada+1
Cape Verde+238
Caribbean Netherlands+599
Cayman Islands+1
Central African Republic+236
Chad+235
Chile+56
China+86
Christmas Island+61
Cocos (Keeling) Islands+61
Colombia+57
Comoros+269
Congo - Brazzaville+242
Congo - Kinshasa+243
Cook Islands+682
Costa Rica+506
Croatia+385
Cuba+53
Curaçao+599
Cyprus+357
Czechia+420
Côte d’Ivoire+225
Denmark+45
Djibouti+253
Dominica+1
Dominican Republic+1
Ecuador+593
Egypt+20
El Salvador+503
Equatorial Guinea+240
Eritrea+291
Estonia+372
Eswatini+268
Ethiopia+251
Falkland Islands+500
Faroe Islands+298
Fiji+679
Finland+358
France+33
French Guiana+594
French Polynesia+689
Gabon+241
Gambia+220
Georgia+995
Germany+49
Ghana+233
Gibraltar+350
Greece+30
Greenland+299
Grenada+1
Guadeloupe+590
Guam+1
Guatemala+502
Guernsey+44
Guinea+224
Guinea-Bissau+245
Guyana+592
Haiti+509
Honduras+504
Hong Kong SAR China+852
Hungary+36
Iceland+354
India+91
Indonesia+62
Iran+98
Iraq+964
Ireland+353
Isle of Man+44
Israel+972
Italy+39
Jamaica+1
Japan+81
Jersey+44
Jordan+962
Kazakhstan+7
Kenya+254
Kiribati+686
Kosovo+383
Kuwait+965
Kyrgyzstan+996
Laos+856
Latvia+371
Lebanon+961
Lesotho+266
Liberia+231
Libya+218
Liechtenstein+423
Lithuania+370
Luxembourg+352
Macao SAR China+853
Madagascar+261
Malawi+265
Malaysia+60
Maldives+960
Mali+223
Malta+356
Marshall Islands+692
Martinique+596
Mauritania+222
Mauritius+230
Mayotte+262
Mexico+52
Micronesia+691
Moldova+373
Monaco+377
Mongolia+976
Montenegro+382
Montserrat+1
Morocco+212
Mozambique+258
Myanmar (Burma)+95
Namibia+264
Nauru+674
Nepal+977
Netherlands+31
New Caledonia+687
New Zealand+64
Nicaragua+505
Niger+227
Nigeria+234
Niue+683
Norfolk Island+672
North Korea+850
North Macedonia+389
Northern Mariana Islands+1
Norway+47
Oman+968
Pakistan+92
Palau+680
Palestinian Territories+970
Panama+507
Papua New Guinea+675
Paraguay+595
Peru+51
Philippines+63
Poland+48
Portugal+351
Puerto Rico+1
Qatar+974
Romania+40
Russia+7
Rwanda+250
Réunion+262
Samoa+685
San Marino+378
Saudi Arabia+966
Senegal+221
Serbia+381
Seychelles+248
Sierra Leone+232
Singapore+65
Sint Maarten+1
Slovakia+421
Slovenia+386
Solomon Islands+677
Somalia+252
South Africa+27
South Korea+82
South Sudan+211
Spain+34
Sri Lanka+94
St. Barthélemy+590
St. Helena+290
St. Kitts & Nevis+1
St. Lucia+1
St. Martin+590
St. Pierre & Miquelon+508
St. Vincent & Grenadines+1
Sudan+249
Suriname+597
Svalbard & Jan Mayen+47
Sweden+46
Switzerland+41
Syria+963
São Tomé & Príncipe+239
Taiwan+886
Tajikistan+992
Tanzania+255
Thailand+66
Timor-Leste+670
Togo+228
Tokelau+690
Tonga+676
Trinidad & Tobago+1
Tunisia+216
Turkey+90
Turkmenistan+993
Turks & Caicos Islands+1
Tuvalu+688
U.S. Virgin Islands+1
Uganda+256
Ukraine+380
United Arab Emirates+971
United Kingdom+44
United States+1
Uruguay+598
Uzbekistan+998
Vanuatu+678
Vatican City+39
Venezuela+58
Vietnam+84
Wallis & Futuna+681
Western Sahara+212
Yemen+967
Zambia+260
Zimbabwe+263
Åland Islands+358

Legal Guardian Email *

About the Patient/Child

Patient/Child's Full Legal Name *

First

Middle

Last

Patient's Preferred Name (If different than above). *

Patient/Child's Date of Birth

Patient/Child's Sex Assigned at Birth

Female
Male
Prefer not to say

Patient/Child's Sex Preferred Pronouns

She/Her
He/Him
They/Them
Other

Patient/Child's Address

Address Line 1

Address Line 2

City

State

Zip Code

Has Child experienced physical or sexual abuse, or neglect?

If yes, brief description of abuse...

At what age?

Insurance Information

Check the appropriate box(es) below regarding patient/child health insurance provider.

Medicaid (including all 5 Medicaid Managed Care Plans)
Blue Cross & Blue Shield
NC Choice
TriCare
United Health Care/UMR
No Insurance - Medicaid application has not been completed
No Insurance - Medicaid has been denied
Other

If other, please enter name of insurance provider below

Who is the Patient/Child's Primary Care (Medical) Provider or Pediatrician?

Is another organization requesting that an appointment/assessment be completed?

Social Services (DSS)
Juvenile Justice (DJJ)
Foster Care Organization
Other

If other - please explain below

Has patient/child been admitted to a hospital in the last 90 days?

Yes - for medical needs
Yes - for mental health needs
No

Please include information for anyone that will need to communicate with our providers about the patient/child's treatment that are NOT their legal guardian. *

First

Middle

Last

What is their relationship with the patient/child? (ex. parent, step-parent, other healthcare provider, DSS Worker, etc.)

Please choose the location that is most convenient for your appointment.

1501 Dock St, Wilmington NC
20 Medical Campus Dr #106, Supply, NC
311 S. McNeil, Burgaw, NC (opening in Summer 2024)

Is there anything else you think we should know?

Thank you for taking the time to complete this form. A member of our Team will contact you within 1-2 business days to discuss the next steps for scheduling an appointment. ** If you have urgent concerns that the child is being abused, about the safety or wellbeing of this child or others, please call 911 or your county's Dept of Social Services.

Thank you for your interest in Clinical/Therapy Services at the Carousel Child Advocacy Center. This form will take approximately 5 minutes to complete. Once completed a member of our Team will contact you within 1-2 business days to discuss the next steps for scheduling an appointment.

If you need to schedule a CHILD MEDICAL EXAM (CME) please contact a family advocate at 910-254-9898 or email franchesca.ramirez@carouselcenter.org to request the CME referral form and staff your case further

About the Patient/Child

Insurance Information

Carousel Child Advocacy Center. Where Healing Begins. Services Revolve Around the Needs of the Child

Carousel Child Advocacy Center. Where Healing Begins.
Services Revolve Around the Needs of the Child