Referral - HumanWorks Collective

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1315 E. Sunset Dr. Suite 203 Monroe, NC 28112
980‑469‑8034
admin@humanworkscollective.com

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Referral

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We appreciate client referrals! To send one, please fill out the referral form below and leave the rest to us.

Name of Referrer *

First

Last

Agency Name *

Date of Referral *

Agency Address *

Agency Email *

Agency Phone Number *

Consumer Name *

Date of Birth

Age

Social Security Number

Gender

Male
Female

Employed

Yes
No

Grade

Race

African American
Caucasian
Native American
Latino
Asian

Funding Source

Medicaid
Medicare
Aetna
Ambetter
BCBS NC
BCBS SC
Tricare
United Healthcare

Employee Assistance Program

Name *

Private Insurance

Parent/Legal Guardian

Medication(s)

Client Address

Client Email Address

would Parent/Legal behaviors

Phone (Home)

Work

Cellphone

Reason for referral (recent or current behaviors in home or community)

To the best of your knowledge please check the service that you feel would best assist this client

DWI
SACOT/SAIOP
Parenting
Sex Offender Treatment
Individual Therapy OPT (Mental Health or Substance Abuse)
Anger Management
Domestic Violence
Intensive In Home (IIH)
Community Support (CST)
Medication Management
Laboratory Urinalysis
Suboxone Treatment
Peer Support

Consent

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.

Right Care, Right Place: Office, home, school, community, or telehealth your choice. We honor your culture, values, and pace in every service we provide.

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Home
About Us
Services
What Sets Us Apart
Contact Us

Services

Outpatient Therapy
Peer Support
SAIOP / SACOT
Programs (Short‑Term & Skills‑Focused)
Intensive In‑Home (IIH)
Community Support Team (CST)
Care Supports (On Request)
Agency Consulting (For Human Services Organizations)
Program Development & Training
Human Resources Consulting
Insurance & Access

Information

Phone

980‑469‑8034

Email

admin@humanworkscollective.com

Address

1315 E. Sunset Dr. Suite 203 Monroe, NC 28112

Business Hours

Mon - Thu: 8:30am - 5:00pm
Friday: 8:30am - 12:00pm

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