Referral Form

Welcome to the New Leaf Behavioral Health referral portal. > Whether you are a community member seeking counseling for yourself, or a healthcare provider referring a patient, we are here to help. Please fill out the secure form below with as much detail as possible.

Self-Referrals: If you are reaching out after hours or prefer not to call, simply provide your information below and our intake team will follow up with you promptly during normal business hours.
Referring Providers: Please include your contact information alongside the patient’s details so we can ensure seamless coordination of care.

Please note: This form is not for emergencies. If you are experiencing a mental health crisis, please call 988 or go to your nearest emergency room.

Referral Date

Referred By

Please enter the information below for the referred individual.

First Name

Preferred Name

Last Name

Date Of Birth

Gender

Ethnicity

Street Address

City

State

Zip Code

Mobile Phone

Home Phone

Parent/Guardian Name

Parent/Guardian Relationship

Primary Insurance

Primary Insurance Number

Secondary Insurance

Secondary Insurance Number

Reason for Referral

Scheduling Preferences

Phone

This field is for validation purposes and should be left unchanged.

Referring Provider Information

Provider Agency: *
Provider Name: *
Phone: *

For Medicaid Referrals Only

Provider NPI:
Carolina Access #:

Client Information

First Name: * Last Name: *
DOB: (MM/DD/YYYY) *
Child/Adult: Gender:
Address: City: State: Zip:
Phone: * Alternate Phone:
Reason for Referral: *

For Children Only

Parent/Guardian: Relationship to child:
Address (if different): City: State: Zip:
Phone (if different): Alternate Phone:

Insurance Information

Insurance:
Insurance Provider:
Policy #/Subscriber ID: Relationship to Insured:
Secondary Insurance Provider:
Secondary Policy #: Relationship to Insured: