Make a Referral

Referral Form

We provide free mental health screenings and treatment to adults (18 years+) with refugee status living in Buncombe, Cabarrus, Craven, Charlotte-Mecklenburg, Forsyth, Gaston, Guilford, Wake, Durham, or Orange counties. At this time, we are only able to serve people who were resettled in the US less than 5 years ago.

To refer someone for free screening and treatment services with the UNC Refugee Mental Health and Wellness Initiative (Refugee Wellness), please fill out the form below. Please provide as much information as possible, including your name and contact information so we may contact you for more information or to follow-up about a client's status. Please notify clients that you are making a referral and explain the referral to them (sample dialogue is included below).

After receiving the referral, we will contact the refugee to conduct an initial screening and to obtain consent to share information with the referring agency. If we obtain consent to share information with you we will follow-up with results and next steps.

For any questions about the status of a referral or to provide additional information, please call our program coordinator Marlowe Crews Kovach at 919-670-0072.

On average, it takes around 1-2 weeks for our team to process your referral and reach out to the person you referred. Referrals received between 12/21/2020-1/8/2021 will not be processed until 1/13/2021. For urgent matters, contact our program coordinator Marlowe Crews Kovach at 919-670-0072 or our Director Josh Hinson at 919-962-6434.

Refugee Wellness does not have 24 hour emergency response coverage. Please contact 911 or go to the nearest emergency room for life threatening emergencies. For other crises (rent, housing, family violence, etc), contact 211 for information about local resources. Interpretation is provided by 211 if you ask.

If you or someone else is having thoughts of suicide, call Alliance Crisis Line (800) 510-9132 (Durham and Raleigh) or Cardinal Crisis Line (800) 939-5911 (Chapel Hill/ Carrboro) to immediately speak to a trained professional. Interpretation is provided if you ask.

Thank you, we look forward to meeting the person you referred as soon as possible.

Explaining Referrals to Clients

"I would like to refer you to Refugee Wellness, a program that provides counseling services. After I make this referral, staff and students will set up an appointment to ask you questions about how you are feeling in your body and your mind. They will ask you about sadness, worries, body aches and pains, and other things that are bothering you. It is normal to refugees to feel these things, and many refugees ask for help managing stress in a new country. Are you interested in speaking with someone from Refugee Wellness? If so, I will give them your name, phone number, and some information about you and they will call to talk with you in the next few weeks."

Person Making Referral*

First Last

Agency Name (if applicable)*

Email of Person Making Referral*

Date of Referral*

Phone*

Fax

Client Information

Name*

First Last

Date of Birth

If date of birth is unknown, please enter partial information or age below.

Gender*

M
F
Prefer not to say

Phone*

Best Day/Time to Reach Client

Please tell us the days of the weeks and times of the day when we are most likely to be able to reach the client, based on his/her work schedule and other commitments.

Address*

Street Address Apartment/Unit # City

County*

Language(s)*

(fill in up to three languages spoken)

Language 2

Language 3

Needs interpreter?*

Yes
No

Nationality*

If other, please identify nationality here

Race

Ethnicity (ex: Banyamulenge, Karen, Kurdish, Pashtoon, etc.)

Date of arrival

Is client aware of the referral?

Yes
No

To refer people to our groups, we have this form that allows you to send multiple entries at the same time.

Make a Referral

Referral Form

Explaining Referrals to Clients

Client Information