School Based Referrals
1
Referring Source
Referring Agency
What agency is sending this referral? Please include a contact name and phone number.
2
Patient Information
First Name
Last Name
Middle Initial
Date of Birth
Assigned Sex at Birth
Male
Female
Preferred Name (Optional)
Preferred Pronouns (Optional)
She/Her/Hers
He/Him/His
They/Them/Theirs
Current MAHEC Patient? (Optional)
Please select
all
departments you currently see at MAHEC
Internal Medicine
Family Medicine
Center for Psychiatry and Mental Wellness
Dental
OBGYN
Race
Asian
Native Hawaiian
Other Pacific Islander
Black/African American
American Indian/Alaska Native
White
Unreported / Refused to report
More than 1 race
Ethnicity
Hispanic / Latino
Not Hispanic / Latino
Unreported / Refused to report
Primary Language
American Sign Language
Arabic
Brazilian Portuguese
Chinese
Chinese (Cantonese)
Chinese (Mandarin)
Czech
Danish
Dutch
English
Farsi
Filipino
Finnish
French
French Canadian
German
Greek
Hindi
Hmong
Hungarian
Indian
Italian
Japanese
Khmer
Korean
Lao
Maori
Mien
Norwegian
Oromomaffia
Other
Polish
Portuguese
Russian
Slovak
Somalia
Spanish
Swahili
Swedish
Tagalog
Thai
Turkish
Tygrinia
Ukrainian
Undefined
Vietnamese
Visayan
Language Spoken at Home
American Sign Language
Arabic
Brazilian Portuguese
Chinese
Chinese (Cantonese)
Chinese (Mandarin)
Czech
Danish
Dutch
English
Farsi
Filipino
Finnish
French
French Canadian
German
Greek
Hindi
Hmong
Hungarian
Indian
Italian
Japanese
Khmer
Korean
Lao
Maori
Mien
Norwegian
Oromomaffia
Other
Polish
Portuguese
Russian
Slovak
Somalia
Spanish
Swahili
Swedish
Tagalog
Thai
Turkish
Tygrinia
Ukrainian
Undefined
Vietnamese
Visayan
3
Insurance Information
Insurance
Please type in any insurance information you may have for the patient. Please type "NA" if none or unknown.
4
Contact Information
Parent or Guardian Name
Email
Phone
Street Address
Apt, suite, unit or floor #
City
State
Zip
5
Referral Details
Reason
Please briefly describe the primary reason(s) that the patient is requesting services.
Please note that if the patient becomes a MAHEC client, this description will be included in the referral that is saved to the patient’s chart.
6
Additional Referral Details
Alternate Phone to above Parent/Guardian contact phone
School
AC Reynolds High
AC Reynolds Middle
Asheville High/SILSA
Asheville Middle
Avery's Creek Elem
Barnardsville Elem
Bell Elem
Cane Creek Middle
East McDowell Middle
Eastfield Global Magnet
Estes Elem
Evergreen Community Charter School
Fairview Elem
Foothills Community
Glen Arden Elem
Glenwood Elementary
Hall Fletcher Elem
Haw Creek Elem
Ira B Jones Elem
Koontz Intermediate
Madison Early College
Madison High
Madison Middle
McDowell Academy for Innov & Early College
McDowell High
Montford North Star
Nebo Elem
Nesbitt Discovery
North Buncombe Elem
North Buncombe High
North Buncombe Middle
North Windy Ridge Intermediate
Oakley Elem
Old Fort Elem
TC Roberson High
Unknown/Other
Valley Springs Middle
Weaverville Elementary
Weaverville Primary
West Marion Elem
West McDowell Middle
Please fax additional patient documentation related to this referral to
828-333-5465