Please enter the following information to complete a referral for the Durham LRC
Client Profile
Name
*
First Name
Middle Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Date
Opus #
Personal Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
General Information
Referral Date
*
-
Month
-
Day
Year
Date
Referral Source
*
NC DPS Staff / Probation Officer
Law Enforcement
JSD Staff
TASC
Family Member
Self
Other
Case Manager Name
First Name
Last Name
Case Manager Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Case Manager Email
example@example.com
PPO Name
First Name
Last Name
PPO Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
PPO Email
example@example.com
Is the client currently in custody?
*
Yes
No
Name of Facility
If you answered Yes to the above question, please let us know your current location.
Is the client currently receiving services from Substance Use Disorders or Mental Health Provider?
Yes
No
Reason for Referral
*
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Copy of Your Submission
To receive a copy of your submission, please fill out your email address below and submit.
Email
example@example.com
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