Referral Interest Form

Thank you for your interest in RHA Health Services! This form is intended for those interested in disability services in North Carolina, Georgia and Tennessee. Please complete all required fields notated with an asterisk. If there is a field or question you do not understand, please select “Unknown.”

In addition, please email supporting documents (i.e., psychological evaluation, Behavior Support Plan (BSP), Individual Support Plan (ISP), and Individualized Education Program (IEP) to the state e-mail where you are seeking services:

North Carolina: referralsnc@rhanet.org
Tennessee: referralstn@rhanet.org
Georgia: referralsga@rhanet.org

If you need any assistance, please contact the RHA Call Center at 1.800.848.0180.

Date: Apr 27, 2024

Applicant Information

What state are you for looking services in?

What services are you looking for?

Is this an emergency placement?

First name of person to receive services

Last name of person to receive services

Birthdate Please enter the DOB in the format "MM/DD/YYYY". If you don’t know the precise date, please enter January 1st.

Gender

Wheelchair accessibility needed

Applicant’s current physical address

Street

City

State

Zip

County

County preference

Distance preference from current location

Current living arrangement

Does the applicant have an appointed guardian?

Legal Guardian First Name

Legal Guardian Last Name

Legal Guardian Relationship to Applicant

Legal Guardian Primary Phone Please enter the phone number in the format "123-456-7890"

Legal Guardian Secondary Telephone Number Please enter the phone number in the format "123-456-7890"

Primary diagnoses

Mild IDD

Moderate IDD

Severe IDD

Profound IDD

Secondary diagnoses

Autism

Cerebral palsy

TBI

Physical/Medical condition (check all that apply)

Seizure

Diabetes

Tracheostomy tube

Gastrostomy tube

Mental health diagnoses (check all that apply)

Anxiety disorder

Bi-polar/mood disorder

Schizophrenia

Dementia

Significant behavioral conditions (check all that apply)

Self-injurious behaviors (harms self)

Aggression

PICA (eating inedible items)

Leaving area

Funding Information

Are you out of state?

Do you know what specific services you are seeking?

Who is making the referral?

Contact Information for Referral Source

Who can we contact with additional questions?

First name of contact

Last name of contact

Phone number Please enter the phone number in the format "123-456-7890"

Email address

Fax number

Best time to contact

By checking this box you’re confirming you’d like to receive emails from RHA Health Services

How did you hear about RHA health services?