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Adult & Youth Services

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Eligibility Requirements

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Phone: (980)-207-0072 Fax: (980)-207-0012

Email: info@maysllc.org

5624 Executive Center Dr. Suite 105, Charlotte, NC 28212

117 Wortham Street, Wadesboro, NC 28170

211 S. Centre St. Suite 420 Statesville, NC 28677

242 2nd Street, Cheraw, S.C. 29520

Referral Form

Date of Referral/Screening

Referring Agency/Person

Consumer's First name*

Consumer's Last name*

Address

Phone

Email Address*

Date of birth*

Account #

Diagnostic Assessment Needed?*

Yes

No

Race

Sex

Marital Status

Medication*

Yes

No

DSS Custody*

Yes

No

Parent or Legal Gardian's Name

Relationship to Consumer*

Parent/Guardian's Address

Parent/Guardian's Main Phone

Parent/Guardian's Work Phone

Parent/Guardian's Email Address

Type(s) of Service(s) requested

Therapy > Individual/Family/Group Therapy

Assessments > Substance Abuse Counseling/Assessments

Support > Case Support

Support > Peer Support

Support > Individual Support

Management > Medication Management

Assessments > Behavior Health Assessments

Something Else

Additional information for Something else.

Reason for the request*

Poor performance in School

Poor Attention Span

Loneliness

Depression or Sad Often

Grief or loss of a loved one

Hearing voices

Feeling Anxious

Panic Attacks

Drug or Alcohol Use

Suicidal Thoughts

Physical Abuse

Domestic Abuse

Restlessness

Isolation

Lack of Confidence

Learning Disability

Post-Traumatic Stress

Hyperactive

Sleepiness or Fatigue

Obsessive Eating

Weight Gain

Not Listed

Other

Disposition*

Referral to other services

Proceed with Admissions process

**** Note: Upon request for services, you must be able to provide a copy of your formal ID, current insurance and Social Security card.

Signature/Title of person completing the Referral and Screening Information*

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Date picker*

Referral & Screening Form

Revision 2/1/22

Posted

Initials of person completing*

I declare that the info I’ve provided is accurate and complete.

We are available

Monday-Friday

9:00 AM EST - 5:00 PM EST

Saturday by Appointment

Estamos disponibles

Lunes - Viernes

9:00 AM EST - 5:00 PM EST

Sabado con Cita

Phone: (980)-207-0072

Fax: (980)-207-0012

info@maysllc.org

5624 Executive Center Dr. Suite 105

Charlotte, NC 28212

117 Wortham Street

Wadesboro NC 28170

211 S. Centre St. Suite 420

Statesville, NC 28677

242 2nd Street

Cheraw, S.C. 29520

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