Intake and Referral Form | A Caring Alternative

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Intake and Referral Form

Start the process of care by completing our Intake and Referral Form. This secure, easy-to-use form helps our team quickly understand your needs and connect you with the appropriate services and support.

Referral Information

Referral Date*

Month

Day

Year

Referral Source*

What Services Are Needed*

Adult Services

Child Services

Child & Family Services

Client Demographics

Client's First Name*

Client's Last Name*

Client's Phone*

Client's Date of Birth*

Month

Day

Year

Client's Social Security Number

Client's Home Address

Country/Region*

Address*

City*

Zip / Postal code*

Client Gender*

Military

Client Race (Select as many as needed)*

White

African American

Asian

Hispanic

American Indian/Native Alaskan

Hawaiian/Pacific Islander

Other

Insurance Coverage*

Medicaid/NCHC

Carolina Access

Medicare

Private

Other

Client County of Residence*

Client Primary Care Physician*

Guardian Information

Does the Client Have a Guardian?*

Yes

No

Residential Setting

Current Residential Setting*

Private Residence

Unsheltered

Shelter

Group Home

AFL

TFC/Foster Care

Other

Resident Contact Person Name and Information (If Applicable)

Emergency Contact Name and Relationship to Client

Emergency Contact Phone

Education and Development Information

Is the client currently enrolled in school?*

Yes

No

Client's current grade or highest level of education completed.*

Does the client have intellectual developmental delays, traumatic brain injury resulting in regression or loss of skills, autism, etc.?*

Additional Information

Please inform us of any accommodations needed such as requiring assistive technology, or due to culture, religion, sexual orientation, disability, socioeconomic status, etc.:*

Presenting need for services (include number of hospitalizations within the last 2 years as well as current diagnoses or diagnostic impressions).

ICD 10-Code Psychiatric and Medical Disorders

Email*

Signature*

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Type Full Name*

Signature Date

Month

Day

Year

Please upload any documentation necessary for referral here.

828-437-3000
info@caringalternative.com

P.O. Box 1536

Morganton, NC 28680

© 2026 A Caring Alternative

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