Referral Forms

Bridging the Gap Between Primary Care and Behavioral Health

CCNC, in partnership with other stakeholders, has developed a set of three referral forms for primary care and behavioral health providers to facilitate easier consultation and communication. Initially released in Spring 2012, the forms have been updated based on feedback received from our partners.  A summary of revisions to the forms is available here and instructions for using the forms are available here.

Form #1 – Behavioral Health Request for Information – this form is for behavioral health providers who begin working with a new consumer or identify a potential medical need, and wish to make contact with the PCP.

Form #2 – Referral to Behavioral Health Services Section I – this form is for PCPs to make a direct referral to a behavioral health provider for an assessment and/or services.

Form #3 – Behavioral Health Feedback to Primary Care Section II – this form is to be used in conjunction with the 2nd form listed above. It is for behavioral health providers to complete and send back to the PCP after receiving a referral.

For your convenience, these forms are downloadable at right as either PDFs (fillable form fields) or MS-Word documents.

***Providers are encouraged to obtain consent for release of information, as is necessary in the sharing of substance abuse information.