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
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
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, Kristy
Ager, Austin
Auditor, Auditor
Austin, Helen
Ayers, Leighann
Baham, Nicole
Bailey, Talahia
Barnwell, Pam
Bates, Constance
Bishop, Brittany
Boyd, Rachael
Boyer, Tina
Branch, Shayonna
Brehon, Nicole
Brown, Craig
Burgess, Ronetta
Burnette, Steva
Butt, Matt
Cantrell, Sherry
Carlton, Tori
Davis, Anndria
Domby, Mark
Duncan, Becky
East, Starr
Eckles, Shonika
Ellixson, Cheryl
Gaither-Goode, Teresa
Garrison, Breona
Gilham, Caylee
Goodson, Sandra
Grice, Patrice
Hall, Kiara
Hamilton, Jon
Hamilton, Jordan
Hamilton, Octavia
Hamilton, William
Harris, Julian
Hayes, Ebony
Herrmann, Teri
Hibiske, Kristin
Hicks, Layla
Holmes, Kendra
Ingram, Fred
Locklear, Katelyn
Louis, Judithe
Marshall, Cassie
McCants, Alaina
McCauslin, Taskina
McFadden, LaTonya
McGee, Marie
Mitchell, Melissa
Murphy, Kathryn
Network, Sparc
Network, SparcFCT
Newman, Jennifer
O'Briant, Lahoma
Porter, Isabella
Proffitt, Amy
Proffitt, Jeremy
Rabenold, Sarah
Reid, Abram
Rhoney, Chelsea
Robinson, Toni
Rodgers, Crystal
Ross, Keturah
Secaluya, Ads Lou
Starling, Nikkie
Steele, Anthony
Stevens, Arthur
Stubbs, Kelsy
Suggs, Melanie
Teague, Ashley
Thompson, Derrick
Tillman, Veronica
Truesdale, Toya
User, Admin
Vareene, Leona
Vennable, Andrea
Ward, Michael
Wayenberg, Lauren
Webb, Steven
Williams, Kayla
Williams, Vanessa
Wilson, Faren
Woody, Shanda
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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