Referral Screening Verification Process (RSVP)

Does the individual being referred have a guardian?

If the individual has a guardian that is considered a “guardian of the person” or “general guardian,” but not the “guardian of the estate,” that guardian must be notified before making the referral.

Referrer first name

Referrer last name

Referrer phone number

Referrer email address (optional)

Individual first name

Individual last name

Individual date of birth (Example: 5/19/1956)

Individual gender

Individual phone number

Individual e-mail address (optional)

Admission Date Required

ACH Admission Date

Help

Enter date individual was admitted to ACH or date expected to be admitted to ACH.

[ X ]

SPH Admission Date

Help

Enter date individual was admitted to State Psychiatric Hospital.

[ X ]

Admission Date

Reason for referral (select all that apply)

Substance use

Traumatic brain injury (TBI)

Intellectual/developmental disability

Personal care services (PCS)

Is the individual potentially eligible for Medicaid?

Last four digits of individual's Social Security number

Individual's county of residence

LME-MCO:

Add any additional information about the individual that you think is necessary to assist in the screening process (ex: past hospitalizations, medications, history of diagnoses, medical conditions, other insurance coverage, etc.)

*RSVP is not able to accept uploads. Please provide contact email address and telephone so that collateral documentation can be gathered during the upcoming screening process. Please also list the collateral documents that can be provided. (Example: abcd@maryshospital.com, 555-555-1234, Comprehensive Clinical Assessment, Psychological Assessment, Hospital Intake/Discharge? paperwork, etc.)

For assistance, email TCLD.Support@DHHS.NC.GOV

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Referral Screening Verification Process (RSVP)

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