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CCAC Referral Interest Form
Laurie Taylor
Please enable JavaScript in your browser to complete this form.
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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
[email protected]
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.)
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
Legal Guardian Email
*
Next
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
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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
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Has Child experienced physical or sexual abuse, or neglect?
Yes
No
If yes, brief description of abuse...
At what age?
Next
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.
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