Outpatient Referral Form | Carolina Family Services

Section 1 of 6

Who is making this referral?

You can refer yourself, a family member, or someone you support. Enter your details here.

Referral source or agency

Referring yourself? Enter “Self.” A parent or guardian can enter “Parent/guardian.”

Your name

Your email address (required)

Your phone number

Fax number (if applicable)

If referring someone else, have you informed the family?

Yes No

What was the family's response?

Section 2 of 6

Tell us about the client.

The client is the person who will receive services. Complete the demographic details you know; leave fields that do not apply blank.

Client first name (required)

Client last name (required)

Client middle name

Client date of birth (required)

Client primary language

If the language is not listed, include it in the additional information in Section 5.

Client sex at birth

Client race

Client marital status

School (if applicable)

If the school is not listed, leave this blank and include its name in the additional information in Section 5.

For a child: do they live at home?

Where and with whom is the child currently living?

Section 3 of 6

How can we reach the client or guardian?

Adults referring themselves: enter your own contact details. For a child or a client with a legal guardian, enter the parent or legal guardian's contact details.

Contact first name

Contact last name

Contact phone number (required)

Contact email address

Street address

Apartment, suite, or unit

City

State

Use the two-letter abbreviation, such as SC.

ZIP code

Contact primary language

Do you approve electronic communication (text/email)?

Section 4 of 6

Coverage and accommodations.

If you are unsure about coverage, leave the answer blank and contact Intake for help. Selecting an insurance option does not confirm coverage for services.

Does the client have private or commercial insurance?

This can be the client's own policy or coverage through a parent or another policyholder.

Yes No

Private insurance company

Private insurance member / policy number

Policyholder name

Policyholder date of birth

Is the client covered under Medicaid?

Yes No

Client Medicaid ID

Required when Medicaid coverage is selected. Enter the number as shown on the card.

Client insurance plan

Select the listed plan if known. Private policy details go in the fields above.

What accommodations would help?

Select all that apply. You can describe other needs in Section 5.

Physical Modifications Telehealth Translator

Section 5 of 6

What brings you to CFS?

Tell us about the concerns and support needed. Share the details that will help Intake understand this referral.

Section 6 of 6

Review and send.

Choose a location, share your availability, and check your answers. Your referral is sent only when you select Send referral.

Preferred CFS location

Pickens refers to school-based services, not a CFS office.

Preferred appointment days and times

Share your availability. This is a preference, not a confirmed appointment.

Attach a document (optional)

You can attach one file, such as a recent Diagnostic Assessment. For help sending additional documents, call Intake at (864) 283-0637, ext. 200.

What happens next?

Call Intake at (864) 283-0637, ext. 200 to schedule. If contact has not been made within a week of receipt of the referral, a follow-up call will be made. An email confirmation will be sent once an appointment has been made.

For the first appointment, please bring:

All insurance cards, including primary, secondary, and tertiary coverage.
The client’s Social Security card.
The parent’s driver’s license, if referring a child.

Complete the verification below before sending.

If verification does not load, check your connection or call Intake for help.

Start a referral.

Who is making this referral?

Tell us about the client.

How can we reach the client or guardian?

Coverage and accommodations.

What brings you to CFS?

Review and send.

Check your answers

What happens next?

This website is not monitored for emergencies.