NCWORKS CAREER CENTER AGENCY REFERRAL CARD
Customer Name
Date
Time
Address
City/State
Zip
Contact Number (Home)
Contact Number (Mobile)
Staff Member Making Referral: Staff Phone:
Email:
Referred Agency:
Location:
Referred Staff Member:
Contact Number:
Appointment Date:
Time:
Reason for Referral:
607 Idol Street High Point, NC 27262 336-882-4141
Henderson Building 2301 W. Meadowview Road Greensboro, NC 27407 336-297-9444
NCWORKS CAREER CENTER CONSENT TO RELEASE OF CONFIDENTIAL INFORMATION Name of Customer: ________________________________________________________________________________ Date of Birth: ________________ I hereby authorize the agencies or persons designated below to release to the NCWorks Career Center staff/partner agency any information that is relevant and necessary for the purpose of providing assistance in reaching my goals. Name of Staff/Partner Agencies:
Information to Be Released:
I understand that I may choose to give or withhold consent. I understand that my records are protected under federal regulations governing confidentiality. My signature provides permission for the above-mentioned agencies to release information. This consent will expire upon termination from the program or at customer’s request. Signature of Customer: Date: Signature of Staff:
Date: