Referral Support

Connect people with care through referrals

Submit a referral or explore career opportunities while connecting individuals and families with compassionate behavioral health support from our dedicated team today.

Start a Referral

GENESIS HEALING CENTER NC

Client referral form

Please complete the form below with the requested information so our team can review the referral, verify eligibility, and determine the appropriate services.

1. Client / Member Information

Client/Member Full Name

DOB

Preferred Name

Pronouns

Phone

Home Address

City/State/ZIP

County

Parent/Guardian/LRP (if applicable)

Phone

2. Services Requested

3. Insurance Information

Insurance Company / Plan:

Member/Policy #

Group #

Secondary Insurance

Secondary Member/Policy #

Insurance Phone

Medicaid / NCHC ID (if applicable)

LME/MCO / Tailored Plan

Insurance: Please provide all available insurance information. Coverage and eligibility will be verified before services are initiated.

4. Reason For Referral / Presenting Needs

Reason for Referral / Current Concerns / Goals

5. Current Providers / Supports

Primary Care Provider

Phone

Therapist / Counselor

Phone

Psychiatrist / Prescriber

Phone

Care Manager / Coordinator

Agency

6. Safety / Urgent Information

Current thoughts of suicide:

Yes No

Current thoughts of harming others:

Yes No

Current Safety Concerns

For a life-threatening emergency, call 911 or go to the nearest emergency room. For a behavioral health crisis, call or text 988

7. Referral Source

Referred By

Title

Agency / Organization

Phone

Fax

Relationship to Client

Referral Date

8. Additional Information / Documents

Additional Information

Referral acknowledgment: Submission of this form does not guarantee admission or authorization of services. Genesis Healing Center NC will review the referral, verify insurance/eligibility as applicable, and contact the client/referral source regarding next steps.

Ready to start your referral?

Connect with our team today and take the next step toward compassionate behavioral health support for yourself or someone you care about.

Apply Now

Career Opportunities

Join our caring and dedicated team

Explore meaningful career opportunities with a compassionate team committed to supporting individuals and families through quality behavioral health services.

First Name

Last Name

Phone

License / certification (if applicable)

Role you're interested in