The SPARC Network - Referral & Intake Form
Referral Code:
All fields in blue are required.
First Name:
Last Name:
Middle Name:
Suffix:
II
III
IV
Jr
Sr
Date Of Birth:
Gender:
Male
Female
Unknown
Street:
City:
County:
Alamance
Alexander
Avery
Buncombe
Burke
Cabarrus
Caldwell
Caswell
Catawba
Chatham
Cleveland
Davidson
Davie
Forsyth
Gaston
Granville
Guilford
Halifax
Henderson
Iredell
Lincoln
Madison
McDowell
Mecklenburg
Mitchell
Montgomery
Moore
Orange
Person
Pitt
Polk
Randolph
Rockingham
Rowan
Rutherford
Stanley
Stokes
Surry
Transylvania
Union
Vance
Wake
Wilkes
Yadkin
Yancey
State:
Zip:
LME/MCO:
Alliance MCO
Amerihealth Caritas North Carolina
Cardinal Innovations MCO
Caroline Complete Health
Healthy Blue/Blue Cross Blue Shield
Partners Behavioral Health MCO
Sandhills MCO
United HealthCare
Vaya MCO
Wellcare
Insurance Name:
Insurance Id No:
Home Tel:
Bus Tel:
Cell Tel:
Maiden Name:
Nickname:
Marital Status:
Divorced
Married
Separated
Single
Unknown
Race:
American Indian or Alaska Native
Asian
Black or African American
Declined
Native Hawaiian or Other Pacific Islander
Other Race
White
Ethnicity:
Declined
Hispanic or Latino
Hispanic, Cuban
Hispanic, Mexican American
Hispanic, Other
Hispanic, Puerto Rican
Not Hispanic or Latino
Not Hispanic Origin
Unknown
Unreported
Guardian name (if under 18)
Guardian Relationship
Guardian Email:
Referred by (name):
Referral Source:
Adult MH Community Provider
Adult MH Res Provider
Alliance MCO
Cardinal Innovations LME
Child MH Community Provider
Child MH Res Provider
Community hospital psychiatric service
DJJ
DSS
Facility Based Crisis
First responder/clinical home provider
Hospital
Hospital emergency department
Internal
Justice system
LME (STR, Crisis Line, Emerg. Resp. Unit)
Mobile Crisis Team
Other
Other/Unknown
Partners Behavioral Health LME/MCO
Primary care provider
Sandhills MCO
School
Self
Self/Guardian
State ADATC
Vaya Health MCO
Referrer Tel:
Referrer other contact# or email address?
Direct/Self Referral Entered by SPARC Staff :
Adams, Jill
Adams, Kristy
Ager, Austin
Armstrong, Teala
Arnold, Sylke
Arrowood, Emily
Austin, Helen
Ayers, Leighann
Bailey, Roderick
Baldwin, Ebone
Balkcum, LeeAnn
Barnwell, Pam
Baten, James
Bates, Constance
Batten, Audra
Bish, Lindsey
Bishop, Brittany
Boyd, Rachael
Boyer, Tina
Branch, Shayonna
Bullock, Roderick
Burgess, Ronetta
Burnette, Steva
Butt, Matt
Bynes, Orrin
Byrd, Kaitlin
Cagle, ShaNiya
Cantrell, Sherry
Carlton, Tori
Chanelo, Daniela
Cheek, Sydney
Christenson, Kirsten
Collins, Joshua
Cooper, Michael
Crawford, Suzanne
Davis, Anndria
Domby, Mark
Duncan, Becky
East, Starr
Eckles, Shonika
Elusme, Priscille
Fant, Tyreece
Farrell, Kathleen
Fox, Christen
Frizzi, Aden
Fry, Heather
Gaither-Goode, Teresa
Garrison, Breona
Gilbert, Missy
Gilham, Caylee
Goodson, Sandra
Graham, Bonita
Grice, Patrice
Hall, Kiara
Hamilton, Jordan
Hamilton, Octavia
Hargrove, Tiana
Harris, Julian
Herrmann, Teri
Hibberts, Roger
Hibiske, Kristin
Hicks, Layla
Hicks, Tawana
Hillon, Sarah
Holbrook, Rose
Holmes, Kendra
Hurt, Ericka
Ingram, Fred
Jackson, Campbell
Johnson, Sandra
Jones, Nia
Ledford, Crystal
Locklear, Ashley
Louis-Ingram, Judithe
Mann, Elizabeth
Marshall, Cassie
Martin, Joyce
Marx, Jonathan
McAfee, Desmond
McCants, Alaina
McCauslin, Taskina
McGee, Marie
McGinn, Keri-Ann
McKibban, Nicole
McLain, Victoria
Medina, Katelyn
Mitchell, Melissa
Moore, Nicole
Moss, Samuel
Murphy, Kathryn
Mustafa, Rosa
Network, Sparc
Pardner, Sylvia
Paul, Elijah
Porter, Isabella
Potter, Katlyn
Proffitt, Amy
Proffitt, Jeremy
Rabenold, Sarah
Reid, Abram
Rhoney, Chelsea
Robinson, Toni
Rodgers, Crystal
Russo, Amber
Sanders, Destany
Sanders, Jennifer
Secaluya, Ads Lou
Slagle, Shelby
Smith, Kealisha
Starling, Nikkie
Steele, Anthony
Stevens, Arthur
Suggs, Melanie
Sykes, Tyana
Tate, Melisa
Teague, Ashley
Teague, Monica
Thompson, Derrick
Thompson, Lucreatial
Thrasher, Suzanne
Tillery, Faren
Toto, Nicole
Truesdale, Toya
Tyson, Monique
User, Admin
Vega, Geraldo
Vennable, Andrea
Wallin, Lisa
Ward, Cynthia
Ward, Derick
Ward, Michael
Watkins, Monyell
Watkins, Shatayla
Watson, Eric
Wayenberg, Lauren
Webb, Steven
Wheeler, Morgan
Whitaker, Terry
White, Jasmine
Whitesides, Molly
Whitlock, Caroline
Wilcox, Kassondra
Williams, Kayla
Wilson, Miranda
Winters, Kendall
Woods, Taylor
Woody, Shanda
Yancey, Samantha
York, Sandra
Young, Lasandra
Young, Sandra
Zacaroli, Polly
Zimbaldi, Stephanie
Zorn, Dan
Zorn, MaryAnn
Narrative of client's presenting Problem:
What would you have done ?:
Emergency room
No services
Mobile Crisis
Other
no response
Have you been seen for services in the last 90 day:
Yes
No
No Response
If so ,Where:
Recommended Services(s):
Recommented Service(s) other:
Does this client or would anyone in the household benefit from translation services?:
Yes
No
If Yes,Who:
Client Disposition at Referral :
Emergent
Urgent
Routine
File To Upload:
The SPARC Network can only receive complete referrals. A complete referral includes your information and the contact information for the parent or legal guardian (if applicable). Also, if the child is currently receiving MH services, the most current CCA and PCP must be submitted.
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