1860 Armory Road , Parkton NC 28371

Referral Form

Referral Form for Sex Offender Specific Evaluations

Heather Wilkerson, MSW, LCSW

(910) 494-5888

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Court Counselor’s Name:


Court Counselor’s Phone Number:


Court Counselor’s Email Address:


Client’s Next Court Date:


Client’s Name:


Social Security Number:


Birth Date:Medicaid #/Other insurance:


Is there a doctor’s office listed on the Medicaid card?If so, what is the name and phone number of the clinic?


Client’s Address:


Client’s legal guardian’s name?


Client’s legal guardian’s phone number?


Please include copies of the following.


Court Order


Social History


Police Report


Victim’s Statement


CME exam (if available)


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Insurance We Accept

Medicaid: Sandhills, Eastpointe, and Alliance
United Healthcare