Preferred Care Inc. - "Making a difference, one person at a time"
IF YOU HAVE A REFERRAL FOR SERVICES, PLEASE COMPLETE AND SEND TO PREFERRED CARE INC OR MAIL TO:  318 HARRIS AVENUE, RAEFORD, NC 28376. 910-565-2377


NOTE: IF MAKING A REFERRAL FOR CONSUMERS IN SC, PLEASE COMPLETE THE REHABILIATION BEHAVIORAL HEALTH SERVICES REFERRAL FORM AND FAX TO 910-565-2387.

IF MAKING A REFERRAL FOR A CHILD, PLEASE COMPLETE THE RBHS PARENT AGREEMENT FORM (LOCATED IN THE LEFT COLUMN).





REFERRALS
CONSUMER BEING REFERRED:
DATE OF BIRTH
CONTACT NUMBER:
PARENT OR LEGAL GUARDIAN
TYPE OF INSURANCE
INSURANCE IDENTIFICATION NUMBER: (EX: MEDICAID #)
DATE OF REFERRAL:
AGENCY OR PERSON MAKING THE REFERRAL:
CONTACT NUMBER OF PERSON MAKING THE REFERRAL:
CONSUMER'S PRESENTING PROBLEM:
TYPE OF REFERRAL (WHAT SERVICES DO YOU THINK WILL BENEFIT THE CONSUMER?)
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