Intake Forms

Intake Forms

Required Documents

Referral Form for Medical Providers to Complete


• The CCABA Service Order/Referral form must be completed in its entirety and signed by a Medical Doctor (MD), Psychologist (PhD), or Psychiatrist (PsyD) only. Commercial insurance companies and NC Medicaid will only accept signatures on these forms from providers with the forementioned credentials.  

• Tricare clients must have both the CCABA Service Order/Referral Form AND the Tricare DSM-V Checklist signed, to move forward in the intake process.   

• Families using insurance providers NOT including Tricare only have to complete the CCABA Service Order/Referral Form. 

Policies and Procedures

Client Information and Medical History

Insurance Information

Diagnosis Report Submission