Self-Referral Form

Interested in receiving services from NC Brookhaven Behavioral Health? Please complete the following information below to get started and someone from our office will be in contact.

Patient's Information

Name

First Name

Last Name

If an email is unavailable, please type N/A.

Phone

(###)

###

####

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referral & Insurance Information

Gender

Preferred Pronouns

Facility Referring

Reason for Referral

Services Needed

Assertive Community Treatment

Community Support Team

Outpatient Medication Management

Outpatient Therapy

Primary Insurance Name

If this information is unavailable, please type N/A in all primary insurance boxes.

Policy Number

Group Number

Issue or Start Date

Secondary Insurance

Policy Number

Group Number

Issue or Start Date

Recent Hospitalization

Current Medication List

Current Medication

Include each medication, dosage, and prescriber

Previous Diagnosis

Please share any additional information.