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Wings of Flight Center for Change Referral Form
Referral form to start therapy services.
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* Indicates required question
Email
*
Your email
Referred by:
*
Your answer
Preference for Therapy
*
School based
Office
Telehealth
Combination of the above
If from McDowell County Schools, please indicate the school
McDowell High School
East Middle School
West Middle School
McDowell Tech HS
Old Fort Elementary
Nebo Elementary
Eastfield Global Magnet
Foothills Community
North Cove Elementary
Pleasant Garden Elementary
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Any preference for Gender of therapist?
*
Male
Female
Reason for Referral
*
Your answer
Client's name
*
Your answer
Client's DOB
*
Your answer
Client's Address
*
Your answer
Client's phone number
*
Your answer
Who has legal custody if it is a child? If the individual is an adult and does not have a legal guardian, please put n/a.
*
Your answer
Client's email address
Your answer
Type of Insurance- If medicaid and it is known, please share what insurance company for medicaid?
Your answer
A copy of your responses will be emailed to the address you provided.
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