Referral Interest Form

Thank you for your interest in RHA Health Services! This form is intended for those interested in disability services in North Carolina, Georgia and Tennessee. Please complete all required fields notated with an asterisk. If there is a field or question you do not understand, please select “Unknown.”

If you need additional assistance, please contact the RHA Call Center at 1.800.848.0180.

 


Applicant Information


Please enter the DOB in the format "MM/DD/YYYY". If you don’t know the precise date, please enter January 1st.
Applicant’s current physical address
Please enter the phone number in the format "123-456-7890"
Please enter the phone number in the format "123-456-7890"




Funding Information




Contact Information for Referral Source


Who can we contact with additional questions?

Please enter the phone number in the format "123-456-7890"