Make a Referral

Refer yourself or your child here. This form is NOT for providers.

Self Referral Form

Tell us about your provider / Medical Professional. Put NONE if you do not have a provider.

Your Provider

Provider Practice Name

Provider Phone Number

Provider Fax Number

Provide your name or family member info who will be a client.

Client First Name

Client Last Name

Client Birthday required

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?

Mobile Phone Disclaimer: 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.