Children With Complex Needs Referral

Please review eligibility criteria below before submitting a referral:

Children with Complex Needs are ages 5 and under 21, with a developmental and/or intellectual disability AND a mental health disorder diagnosis who are Medicaid eligible AND at risk of not being able to return to or maintain placement in a community setting.

Referral Date*

Member First Name*

Member Last Name*

Member DOB*

Medicaid ID*

Medicaid County*

Name of Referrer*

Referral Source Email Address*

Referral Source Phone Number*

Department/Agency Making Referral*

Reason for referral*

Describe in detail why the member is at risk for being unable to return to the community or unable to remain in the community.

Name of Parent/LRP*

Parent/LRP Phone Number*

Custodian/Parent Email

IDD Diagnosis (clinical documentation required)*

Mental Health Diagnosis (clinical documentation required)*

Has the member been referred to NC START?*

Yes

No

If referred to NC START, what date was member referred?

Tailored Care Management Provider (if applicable)

Care Manager assigned to member (if applicable)

Current Services

Select or enter value

Attach psychological evaluation/proof of IDD and MH diagnosis (required)

Drag and drop files here or

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