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Referrals

Our Referral Form is designed to ensure a smooth transition of care. Once submitted, our team will review the referral and reach out to the client within 48–72 business hours.

* Licensed providers, healthcare professionals, and community partners may use this form to refer clients in need of mental health services. Click here for the full provider referral form and fax it to (910) 364-9946

Self Referral Form

Client Information

Urgency Level
Requested Services
Insurance
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