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Welcome to
Kapital Connections LLC
919-263-9185
919-925-5981
1740 Heritage Center Dr Suite 102 Wake Forest, NC 27587
Home
About Us
Our Services
Careers
Job Application
Referral
Contact Us
Home
About Us
Our Services
Careers
Job Application
Referral
Contact Us
919-263-9185
919-263-9185
Phone Number
[email protected]
Email Address
1740 Heritage Center Dr Suite 102
Wake Forest, NC 27587
Referral
Consumer Name
Gender
Date of Birth
MM slash DD slash YYYY
Medicaid/Insurance#
List Type of Insurance (Medicaid/Private)
Current Address
Phone Number
Emergency Contact Name
Emergency Contact Phone Number
Referring Agency
Phone
Person Making Referral
Phone
Presenting Problems/Reason for Referral
Current Medications
History of any of the following behaviors: (circle) Abusive/ Violent/ Sexually Inappropriate Additional Information (include hospitalizations, medical records, psychological, etc.):
Is the individual currently receiving any other mental health services at another agency?
Has the individual been unsuccessful with other mental health services? If yes, please list other services.
Is the individual currently using any substances or drugs other than prescribed medication?
OFFICE USE ONLY: Referral Recommendations (Please check all that apply)
Behavioral Health/Clinical Assessment
Individual & Transitional Support
Community Living & Support
No referral recommendation at this time
Peer Support
Outpatient Therapy
Other Services
