Make a Referral

Providers or School Counselors, Please use this form to refer a client/students/patient for services.

Provider and School Referral Form

Provider Information below.
If this is a school, please enter school, school counselor information here.

Referring Provider / Counselor

Provider Email

Website

Referring Company or School

Provider Fax Number

Provider Phone Number

Provider Address

Client Patient Information below.

Client First Name

Client Last Name

Client Birthday

Client Address

Grade In School or NA

Phone Number

Best Time to Call

OK to leave a message?

Yes

Guardian Name (if minor)

Guardian Relationship to Minor

NOTE: If a minor has been displaced, under the care of DSS or a court ordered custody situation has been established, please upload guardianship paperwork with this referral. You may submit this after the fact, but before care can be established.

Guardianship Paperwork

Upload File

Upload supported file (Max 15MB)

Primary Insurance Name

Primary Insurance Number

Secondary Insurance Name

Secondary Insurance Number

Substance Abuse Issues?

Yes

If Substance Abuse, plase give details

Medications List and dosage information. Put NONE if client takes no meds.

How can we help with this patient? Other Pertinent Info?

By clicking the box, I agree and acknowledge that Sandhills Best Care may send text messages to my wireless phone number for business-related purposes. Message and data rates may apply. Message frequency will vary and I will be able to opt-out by replying “STOP”. For more information on how my data will be handled, click here in order to review the PRIVACY POLICY.

Make a Referral

Provider and School Referral Form

Provider Information below. If this is a school, please enter school, school counselor information here.

Client Patient Information below.

NOTE: If a minor has been displaced, under the care of DSS or a court ordered custody situation has been established, please upload guardianship paperwork with this referral. You may submit this after the fact, but before care can be established.

Provider Information below.
If this is a school, please enter school, school counselor information here.