WAKE LRC
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REFERR
AL FORM
Facility Staff:
Please email the NCDPS Official Transition Documents to WakeLRC@wakegov.com.
Date of Referral
Release/Projected Release Date
Client Information
First Name
Last Name
Age
Date of Birth
Gender
Male
Female
Other
Option D
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Race
Choose an option
African American
Caucasian
Hispanic
Latino
Native American
Item 1
Item 2
Item 3
Item 4
Item 5
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Race, if other.
Last known address (street, city, state, zip)
Phone
Email
Primary Language
Interpreter needed?
Choose an option
Yes
No
Option B
Option C
Option D
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If yes, language or ASL
Computer assistance needed?
Choose an option
No
Yes
Option C
Option D
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Veteran?
Choose an option
No
Yes
Option C
Option D
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MH/SA Diagnosis
Medications
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