Pediatricadvanced_Crisis_substance

Crisis and Emergency Resources (Updated 2024)

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Child's Frist NameChild's Last Name

Date of Birth*

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Please use the following numbers if you are in need of emergency services 24 hours a day, 7 days per week (24/7).

Who to CALL for 24/7 Emergency Support Over the Phone:

For a medical emergency (life-threatening/safety concerns), please go to your closest Emergency Department of your local hospital or call 911.
For a mental health emergency (thoughts of self-harm, suicide, or harm to others), Use the 988 National Suicide and Crisis Hotline
- Call or Text 988
- Utilize 988 Online Chat through their website: 988lifeline.org/
For a mental health emergency where you choose to talk to an on-call PAT Counselor:
- Call PAT on-call line: 980 444 2959 ext. 1023
For mental health support for LGBTQIA+ Youth (thoughts of self-harm or needing someone to talk to), contact The Trevor Project
- Call 1-866-488-7386
- Text ‘START’ to 678-678
- Chat Online at thetrevorproject.org/get-help/

Where to GO for 24/7 In-Person Emergency Support for Kids/Teens:

For a medical emergency (life-threatening/safety concerns), please go to your closest Emergency Department of your local hospital.

For a mental health emergency, (thoughts of self-harm, suicide, or harm to others), please go to your closest Emergency Department of your local hospital

For inpatient behavioral health assessment for youth:

In the Charlotte area, go to:

Atrium Health Behavioral Health Charlotte (behavioral health ED & inpatient care for youth)
501 Billingsley Rd, Charlotte, NC 28211
Phone: 704-444-2400 (available 24/7)
https://atriumhealth.org/medical-services/prevention-wellness/behavioral-health

Novant Health Presbyterian Medical Center (behavioral health inpatient care for youth)
200 Hawthorne Lane, Charlotte, NC 28204
Phone: 1-800-718-3550 (available 24/7)
https://www.novanthealth.org/services/mental-health/child-and-adolescent-programs/
In the Winston Salem area, go to:

Novant Health Forsyth Medical Center (ED only- youth inpatient may be referred out)
3333 Silas Creek Parkway, Wintson-Salem, NC 27103
Phone: 336-718-5000 (ED)
Behavioral Health Call Center: 1-800-718-3550 (24/7-call only)
https://www.novanthealth.org/locations/medical-centers/forsyth-medical- center/services/

Behavioral Health Urgent Care - Daymark (youth and adult short-term observation)
650 North Highland Ave, Suite 110, Winston Salem, NC 27101
Phone: 336-955-8430 (available 24/7)
https://www.daymarkrecovery.org/locations/bhuc-forsyth
In the Asheville area, go to:

Mission Hospital (inpatient care for youth at Sweeten Creek)
509 Biltmore Ave, Asheville, NC 28801
Phone: 828-213-1111 (available 24/7, Ped ER 11AM-11PM)
https://missionhealth.org/services-treatments/trauma-emergency/

C3356 Behavioral Health Urgent Care (will see crisis for age 4 and up, may be referred out to child specialty services)
356 Biltmore Ave, Asheville, NC 28801
Phone: 1-800-848-0180 (available 8AM-8PM)
https://rhahealthservices.org/c3356-comprehensive-care-center/crisis-walk-in- services/#bhuc

Caiyalynn Burrell Child Crisis Center (inpatient for ages 6-17)
277 Biltmore Ave, Asheville, NC 28801
Phone: 877-277-8873 (available 24/7 *Call first for availability, otherwise go to ED)
https://www.daymarkrecovery.org/locations/fbc-buncombe

Who to CALL for Mobile Crisis Support to come to your location:

For Cumberland, Durham, Johnston, Mecklenburg, Orange, and Wake Counties:
- 1-877-223-4617 – Alliance Health
For Burke, Cabarrus, Catawba, Cleveland, Davie, Forsyth, Gaston, Iredell, Lincoln, Rutherford, Stanly, Surry, Union, and Yadkin Counties:
- 1-833-353-2093 – Partners Health
For additional Mobile Crisis in Forsyth County, and Rowan County:
- 1-866-275-9552 – Daymark Mobile Crisis
For Anson, Davidson, Guilford, Harnett, Hoke, Lee, Montgomery, Moore, Randolph, Richmond, and Rockingham Counties:
- 1-800-256-2452 – Sandhills
For Alamance, Alexander, Alleghany, Ashe, Avery, Buncombe, Caldwell, Caswell, Catham, Cherokee, Clay, Franklin, Graham, Granville, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Person, Polk, Rowan, Stokes, Swain, Transylvania, Vance, Watauga, Wilkes, and Yancey Counties:
- 1-800-849-6127 – Vaya Health

I understand that these are the appropriate crisis resources for a behavioral health emergency and that in the case of a life-threatening emergency, I should call 911.

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Substance Abuse Disclosure Consent
42 CFR Part 2 and HIPAA

REMEMBER: Information disclosed pursuant to patient consent must be accompanied by the notice prohibiting redisclosure.

I, name , parent or guardian of child's name , authorize Pediatric Advanced Therapy to disclose much and what kind of information may be disclosed, including on explicit description of what substance use disorder information may be disclosed; as limited as possible to name of individual(s) who will receive the information for the purpose of purpose(s) . I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows: describe date, event, or condition upon which consent will expire, which must be no longer than reasonably necessary to serve the purpose for this consent .

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.

I have been provided a copy of this form in my patient portal.

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