Carolina Case Management - Job Seeking Skills Class (JSS) Referral Form

MDS (Vocational Services) Referral Process
For your convenience, you may refer a case in any of the following ways:

1. Telephone our main office at 800-546-9636 with referral information.

2. Click the following button to download a copy of the CCM Referral Form in portable document format (.pdf). You will need to install Adobe Acrobat Reader on your computer if you do not already have a copy of this free software. You can download Adobe Acrobat Reader and have it installed on your computer in a matter of minutes and will find it very useful. Click here to access Adobe Systems Free download page: Once you have installed Adobe Acrobat Reader, you will be able to RIGHT click on the following link and Save Target As ... to your computer, then open our form with Acrobat Reader and print it.
MDS Referral Form (.pdf)
Complete referral information sheet and fax to 919-846-4740 or
mail to: 118 Wind Chime Court, Raleigh, NC 27615

3. Fill out our electronic form and submit: or,

4. Contact one of the following Customer Account Representatives directly who will come to your office for copying and pick up of the referral:

Mark Marshburn	(919) 649-6207	Mmarshburn@aol.com
Kara Faust	(704) 678-5272	Karalammey@aol.com
Mary Beth Hoye	(919) 274-0091	marybethhoye@nc.rr.com
Michelle Mauney-Lowery	(908) 253-2390	Lowery1999@bellsouth.net

MDS Referral for Vocational Services
Please complete the following form to submit your referral. Hit tab to move to the next entry field. You will be contacted within 48 hours by a Carolina Case Management representative. For immediate assistance during business hours:800-546-9636

WIFE INFORMATION

WIFE Name (First, Middle Initial, Last)
Today's Date

Address
Telephone/FAX

City, State, Zip Code
Email Address

Is this the unskilled/unemployed spouse? YES   NO

WIFE ATTORNEY INFORMATION

WIFE Attorney Name (First, Middle Initial, Last)
Attorney Firm

Address
Telephone/FAX

City, State, Zip Code
Email Address

HUSBAND INFORMATION

HUSBAND Name (First, Middle Initial, Last)
Is this the unskilled/unemployed spouse?
YES   NO

Address
Telephone/FAX

City, State, Zip Code
Email Address

HUSBAND ATTORNEY INFORMATION

HUSBAND Attorney Name (First, Middle Initial, Last)
Attorney Firm

Address
Telephone/FAX

City, State, Zip Code
Email Address

BILLING INFORMATION

Party Responsible for Billing:   Wife   Husband   Other:

Billing Address, if different from above:

Telephone Number, if different from above:

PARTIES TO RECEIVE COPIES OF REPORTS:

WIFE      HUSBAND      WIFE'S ATTORNEY      HUSBAND'S ATTORNEY

REFERRER:

Name:   Email:

Address: Phone:

               Thank you for your referral.