System of Care Brochure

System of Care Handbook

Email System of Care Coordinators

SYSTEM OF CARE FORMS

Please fax all forms to the attention of System of Care at 252-937-6631

Assistance Request Form - This form is for agencies requesting assistance in various areas from System of Care Coordinators.

Authorization for the Disclosure and Reciprocal Exchange of Information - This form covers the confidentiality of the exchanging of information between the Provider and the Care Review Team.  This form is to be filled out and sent in with the Referral Form.

Care Review Action Plan - This form is used during the Care Review meeting. A member of the Care Review team will fill out the form during the meeting. A copy of the complete form will be given to the provider, person completing the form, System of Care Coordinator, and parent or legal guardian.

Care Review Referral - You will be notified by the System of Care Coordinator, after your request form as been reviewed, to send in the referral information packet.

Care Review Request for Out of Home Placement - Fill out when placing a child or adolescent outside of the following counties:  Wilson, Nash, Edgecombe, Greene, Wake, Johnston, Wayne, Lenoir, Pitt, Martin, Halifax or Franklin

Care Review Request for Technical Assistance - When needing technical assistance for residential placement of a child or adolescent.

Care Review Update/Review of Residential Placement - This form is used after the consumer has been placed for 6 months or before discharge, whichever shall come first.

Implementation update #45- Court Involved Youth - Please complete and fax to System of Care.

Notification of Out of Home Community Placement for Children/Adolescents - This is required for children and adolescents placed in residential placements out of their home community.