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
Anson
Avery
Buncombe
Burke
Cabarrus
Caldwell
Caswell
Catawba
Chatham
Cleveland
Craven
Cumberland
Davidson
Davie
Durham
Faulkner
Forsyth
Garland
Gaston
Granville
Guilford
Halifax
Harnett
Henderson
Hoke
Iredell
Jackson
Johnston
Lee
Lincoln
Madison
McDowell
Mecklenburg
Mitchell
Montgomery
Moore
Onslow
Orange
Person
Pitt
Polk
Pulaski
Randolph
Richmond
Rockingham
Rowan
Rutherford
Scotland
Stanley
Stokes
Surry
Transylvania
Union
Vance
Wake
Wilkes
Wilson
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
Trillium
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
Trillium Health LME/MCO
Vaya Health MCO
Referrer Tel:
Referrer other contact# or email address?
Direct/Self Referral Entered by SPARC Staff :
Adams, Jill
Adams, Kristy
Akers, Chantel
Allen, Hannah
Armstrong, Teala
Arrasola, Tanya
Arrowood, Emily
Austin, Helen
Ayers, Leighann
Baldwin, Ebone
Balkcum, LeeAnn
Barnes, Jabreal
Barnwell, Pam
Baten, James
Bates, Constance
Batten, Audra
Battle, Lyndsey
Baum, Jacob
Beam, Tearney
Berry, Gwendolyn
Bish, Lindsey
Black, Gileah
Boose-Manning, Latisha
Boulware, Michael
Boyd, Rachael
Boyer, Tina
Branch, Shayonna
Brandenburg, Lacey
Burgess, Ronetta
Burnette, Steva
Butler, Karethia
Butt, Matt
Byrd, Kaitlin
Carlton, Tori
Chanelo, Daniela
Christenson, Kirsten
Coleman, Adia
Coles-Walton, Danielle
Cook, Shawna
Cooper, Michael
Crawford, Suzanne
Creek, Ashley
Crockett, Monica
Davidson, Brandon
Davis, Anndria
Day, Shenecca
Dellinger, Lauren
Dent-Smith, Kinena
Donnell, Michele
East, Starr
Eckles, Shonika
Evans, Kayla
Fant, Tyreece
Farrell, Kathleen
Fernandes, Sherline
Foard, Jazmine
Ford, Nataya
Fox, Christen
Frizzi, Aden
Fulper, Derek
Garrison, Breona
Gaston, Ashley
Gihwala, Ramesh
Gilham, Caylee
Glover, Attaliah
Goodson, Sandra
Green, Kenneth
Grice, Patrice
Hall, Kiara
Hamilton, Jordan
Harris, Julian
Heggins, Kymon
Henry, Jessica
Herrmann, Teri
Hibberts, Roger
Hibiske, Kristin
Hicks, Layla
Hill, Le'on
Hillon, Sarah
Hofmann, Maddison
Holbrook, Rose
Holden, Jaleesha
Holley, John
Humphries, Treva
Hurt, Ericka
Ingram, Fred
Jones, Nia
Jordan, Davion
Jordan, Stephnia
Keith, Ebony
Kelly, Candice
Kertley, Nikia
Knight, Eric
Ledford, Crystal
Locklear, Ashley
Lopez, Juchia
Louis-Ingram, Judithe
Ludwig, Dawn
Mann, Elizabeth
Martin, Joyce
Mason, Tracy
McCauslin, Taskina
McGee, Marie
McGinn, Keri-Ann
McGirt, Molly
McKibban, Nicole
McKinney, Stacey
McLain, Victoria
Medina, Katelyn
Merrill, Lexine
Minnick, Alison
Mitchell, Breana
Mitchell, Melissa
Mitchell, Sylvia
Moore, Nicole
Moss, Annisa
Moss, Samuel
Murphy, Kathryn
Murphy, Meagin
Nesmith, Kendra
Network, Sparc
Paige, Jamonica
Pardner, Sylvia
Paul, Elijah
Peace, Jasmine
Petty, Wiyle
Phillips-Davis, Rebecca
Pittman, Ebony
Porter, Isabella
Proffitt, Amy
Proffitt, Jeremy
Queen, Chantiza
Rabenold, Sarah
Ray, Trevione
Reed, Briana
Reid, Abram
Rhoney, Chelsea
Robinson, Clarice
Robinson, Néa
Rodgers, Crystal
Roxburgh, Kimberlee
Russo, Amber
Ryan, Michael
Sagrista, Marien
Sanders, Destany
Schenck, Mia
Secaluya, Ads Lou
Short-Sherwin, Kelly
Smith, Devin
Starling, Nikkie
Steele, Anthony
Stevens, Arthur
Stewart, Allie
Stuckes, April
Stukes, Joey
Sykes, Tyana
Tate, Melisa
Teague, Ashley
Teague, Monica
Therapist, Test
Thibodeaux, Josh
Thompson, Derrick
Thrasher, Suzanne
Tillery, Faren
Toto, Nicole
Truesdale, Toya
Tyson, Monique
User, Admin
User, Test
VanBuren Felder, Aaisha
Vega, Geraldo
Vennable, Andrea
Verhaeghe, Sarabeth
Wallin, Lisa
Ward, Cynthia
Ward, Derick
Ward, Michael
Warren, Mandy
Watkins, Monyell
Watson, Eric
Wayenberg, Lauren
Wheeler, Morgan
Whitaker, Terry
White, Jasmine
Whitlock, Caroline
Willis, Tabitha
Wilson, Virginia
Winborne, Jamaar
Woods, Michael
Woods, Taylor
Woody, Shanda
Wright, Nora
Yancey, Samantha
Yates, Jennifer
York, Sandra
Young, Sandra
Zacaroli, Polly
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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