Apply Online

Please complete this online form. Once submitted, one of our Extended Reach team members will review your application and contact you directly within two business days.

Request for Service Intake
DATE OF REFERRAL
REFERRED BY		PHONE #
CLIENT INFORMATION
NAME
ADDRESS
CITY		STATE ZIP
EMAIL ADDRESS
DAY PHONE NUMBER		OK TO LEAVE MESSAGE? --- YES NO
NIGHT PHONE NUMBER		OK TO LEAVE MESSAGE? --- YES NO
Date of Birth	(MM/DD/YY)
Parent/Guardian Name
Parent/Guardian Phone	(if different) Day Night
Sex	--- MALE FEMALE	Marital Status --- Married Single Divorced Separated
Occupation
Current School		Educ. Level/ Highest Grade Achieved
		Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
Current Medications (including over-the-counter) and known drug reactions
Who Presribed?
Known Allergies
Name, Telephone, and Address of Next of Kin
STATEMENT OF CONCERN
Reason for Seeking Service
Desired Outcomes of Service
Use of Substances?	--- YES NO	If yes, what?
		How often?
Previous Mental Health Services?	--- YES NO	If yes. when?
		If yes, where?
History of Abuse?	--- YES NO   Type --- Emotional Physical Sexual Neglect
Legal Involvement?	--- YES NO
	If yes, please describe:
Present or Part Safety Concerns (i.e. suicidal, homicidal): --- YES NO
	If yes, please describe:
Primary Care Doctor		Phone
*** 9-1-1 or 774-HELP (888-568-112) ***
INSURANCE
Select One
Medicaid  Private Ins.  Secondary Ins.  Self Pay   Other
Primary Insurance
Insured SS#	(you may provide this later)
Group Number	Policy Number
Name of Insured
Client's Relationship to Insured
Prior Authorization Obtained? (If Required)	--- YES NO
Primary Insurance
Insured SS#	(you may provide this later)
Group Number	Policy Number
Name of Insured
Client's Relationship to Insured
Prior Authorization Obtained? (If Required)	--- YES NO
ADDITIONAL INFORMATION
Additional Information, Comments, or Questions
Click on the SUBMIT button below to send your application. You will then be redirected to our home page where you can continue to browse our website. One of our team members will contact you within two business days.

Extended Reach Day Treatment
2716 Custer Ave
Fayetteville, NC 28301

Telephone
910.484.0095
Ext 0 or Ext 903

Email
info@extendedreach.org

Sign Your Child Up TODAY!

Hours of Operation
10:00 AM - 8:00 PM

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