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After-Hours Crisis Line for PORT Health Patients
1-866-488-7678
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payment-redirect
Locations
Community Supervision Program Referral (For Department of Adult Corrections referrals ONLY)
Treatment
Adult Services
Counseling & Mental Health Treatment
Outpatient Services
Alcohol & Substance Use Treatment
Medication Assisted Therapy
Facility-Based Crisis
Intensive Outpatient Program
Criminal Justice / Court Ordered Services
Stepping Stone Manor
Kelly House Program
Self Assessment
Youth Services
Outpatient Treatment
Prevention
PORT Residential
Project: F.I.N.D.
NC Lock Your Meds Campaign
Pharmacy
Veteran’s Treatment Court
Employment
Careers
Internships
Employee Benefits Summary
About
Mission and Values
Meet Our Team
PORT News
Resources
Medical Records Request
Videos
Employee Spotlights
Quality Management
Accreditation
Commitment
Testimonials
Grievance
How Are We Doing
ATLAS - Patient Experience Survey
Compliance
Contact
Media
Payments
payment-redirect
Locations
Community Supervision Program Referral (For Department of Adult Corrections referrals ONLY)
A Clear Path to Recovery
PORT Residential
Adolescent Residential Program Form
Are you in crisis?
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1-866-488-7678
Date of referral
*
Date teen available for admission
*
Patient Information
Person served full name and preferred name (if applicable)
*
Date of birth
*
Gender
*
Male
Female
Social security number
*
Parent/guardian name
*
Contact phone numbers for parent/guardian
*
Address of teen (if teen is placed outside of home, please indicate and explain in comment section)
*
Address of parent/guardian (if different from teen)
*
Reason for referral and presenting problem
*
General statement about challenges the teen is experiencing with family, school, home, or legal
*
Diagnosis
*
Substances used/misused by teen
*
Alcohol
Marijuana
Benzodiazepines
Heroin
Pain Pills
Meth
Over-the-Counter medications
Tobacco/Vape/Smokeless Tobacco/Cigarettes
Cocaine
IV drug use
Other
Past hospitalizations and recent treatment history
(please include both inpatient, outpatient, community based services and reason for referral to level of care)
Place and date of service
Type of service
Reason for admission
Comments regarding completion and/or effectiveness
Place and date of service
Type of service
Reason for admission
Comments regarding completion and/or effectiveness
Place and date of service
Type of service
Reason for admission
Comments regarding completion and/or effectiveness
Place and date of service
Type of service
Reason for admission
Comments regarding completion and/or effectiveness
Place and date of service
Type of service
Reason for admission
Comments regarding completion and/or effectiveness
Please list any medical conditions, allergies, or current medication taken by the teen
*
A minimal 30-day supply of medications must be provided by the family at time of admission or the teen may not be admitted to the program.
Legal History
Teen is on probation
*
Yes
No
if yes
Adult
Juvenile
Name of court counselor(s)
Contact number for court counselor
Current pending charges
Court dates that will occur while teen is in treatment at PORT Health
School History
Is teen currently enrolled in school?
*
Yes
No
Name of school
IEP or 504
*
IEP or 504 plan currently
IEP or 504 plan in the past
No IEP or 504
Referral Information
Referring Agency/Person
*
Address
*
Contact Information for Referring Agency
Phone
*
Email
*
Insurance Information
Insurance Provider
*
Policy Number
*
Copy of insurance card must be presented at time of screening, however you may attach a copy to the referral form as well.
Copy of insurance card is attached
*
Yes
No
Required Items/Documents for Admission
Required Items/Documents for Admission
*
TB Skin Test and record of physical exam (required at admission)
Insurance Card
Documents to support past treatment history
Any pertinent court documents
Evidence of a 504 or IEP (if applicable)
Medical history for pre-existing medical conditions
Documents to Upload
Drag 'n Drop your files here!
Signature of Referring Person
*
Clear
Date
*