Issued: November 30, 2022

What is happening?

On Oct. 1, 2022, the six LME/MCOs released a standardized, statewide referral form for use by all Residential Providers and Therapeutic Foster Care (TFC) providers who contract with them. This standardized form will streamline the referral and evaluation process and support the timely identification of appropriate therapeutic placements for children and youth in North Carolina. See initial communication at

To be mindful of the significant demands on providers during the launch of Tailored Care Management, the soft launch of the referral form is extended to January 1, 2023.

The LME/MCOs engaged providers in the form’s initial development. Since its soft launch on Oct. 1, 2022, providers have shared feedback on potential additions and clarifications that will enhance its utility.

The LME/MCOs have reviewed and incorporated these provider recommendations into an updated version of the standardized referral form that is now titled, “Universal Child and Adolescent Residential Placement Referral Form.”

Please begin using this updated version of the form immediately in preparation for statewide implementation on January 1, 2023.

Where can providers access the UPDATED fillable form?

The UPDATED standardized referral form (the “Universal Child and Adolescent Residential Placement Referral Form”) is available at Both fillable .PDF and fillable MS Word versions are available.

Who should providers contact with questions?

If you have questions, please contact us at or by phone at 704-842-6111.

To learn more about the NC Child and Family Improvement Initiative, click here