Referral

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Referral Form

Kindly complete the following form if you were being refered by someone

Referrer's First Name

Referrer's Last Name

Referrer's Address

Referrer's Email

Referrer's Phone:

Client's First Name

Client's Last Name

Date of Birth:

Gender:

Select Insurnace Type

Other Insurance

Client's Insurance Policy Number

Client's Email

Client's Address:

Client's Contact Number:

What time is most suitable to hear from a counselor:

Have Parents Been Informed of Referral (ages 18 or less)

Special Needs/Any other relevant information:

Upload required documents (Image format)

Curative Behavioral Health LLC Moto is “Curing Your Mind” and leading you to happiness one care at a time.

1515 Mockingbird Lane Charlotte, NC 28209 |
9600 Two Notch Rd. Columbia, SC 29223