Patient Referral
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Restoration family services client consent form

If you are experiencing a mental health crisis, you are not alone. Call or text the 988 Suicide & Crisis Lifeline for free, 24/7 confidential support. Just dial 988.


    Referral Information:

    Service(s) Requested:

    Patient Referral Information:


    Diagnoses (please list description):

    Reason For Referral (check all that apply):

    Additional Referral Information (including past hospitalizations, probation/parole, DSS involvement, etc.):



    FOR OFFICE USE ONLY:

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    Stand: 08/01/2022

    RESTORATION FAMILY SERVICES, Inc.

    – Office Locations –
    714 Wilkins Street – Smithfield, NC 27577
    214 Broadway St Suite 7 – Durham, NC 27701
    401 S Market St – Benson, NC 27504

     

    Phone: (919) 938 9502
    Fax: (919) 938 9702

    Email: admin@restorethefamily.org
    www.restorethefamily.org

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    CARF 3 year accreditation for Behavioral Health: Community Integration Respite Services, Alcohol & Drug Addictions, Mental Health Services & DWI Services

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