Georgia Referral Form
ALL INFORMATION SUBMITTED IS CONFIDENTIAL
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I am
*
Client
Parent or guardian
School personnel
DSS Staff
DJJ/Court Staff
Other
Person making the referral
*
First Name
Last Name
Referrer's phone number
*
-
Area Code
Phone Number
Referrer's contact email
example@example.com
Client name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Grade
Client phone number
-
Area Code
Phone Number
Please pick the region where the client resides
Please Select
Chatham County
Chattahoochee County
Cherokee County
Clayton County
Coweta County
DeKalb County
Fayette County
Fulton County
Hall County
Harris County
Heard County
Henry County
Macon-Bibb County
Marion County
Merriwether County
Muscogee County
Pike County
Rockdale County
Spalding County
Talbot County
Taylor County
Troup County
Other
Client Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
Insurance Provider
*
Please Select
Healthy Blue (SC Medicaid)
Absolute Total Care (SC Medicaid)
Molina Healthcare (SC Medicaid)
Human Healthy Horizons (SC Medicaid)
First Choice (SC Medicaid)
Blue Cross Blue Shield (SC)
Peach State Health Plan (GA Medicaid)
CareSource (GA Medicaid)
WellCare (GA Medicaid)
Blue Cross Blue Shield (GA)
UnitedHealthcare (Commercial/Medicaid)
Cigna
Aetna
Other
No insurance
Commercial ID Number
Medicaid ID Number
Reason for referral (select all that apply)
Difficulty focusing or paying attention
Declining grades or academic performance
Truancy or frequent absences
School adjustment or transition concerns
Defiance or oppositional behavior
Aggression or acting out
Impulsivity or hyperactivity
Risk-taking behaviors
Anxiety
Depression or sadness
Anger or irritability
Family conflict
Parent–child relationship issues
Peer or social difficulties
Bullying (victim or perpetrator)
Trauma or grief support
Substance use concerns
Crisis intervention or safety concerns
Other
Parent/Guardian name, if applicable?
First Name
Last Name
Parent/Guardian phone number, if applicable?
-
Area Code
Phone Number
Parent/Guardian Email Address
example@example.com
Program Requested (select all that apply)
Outpatient Counseling
Medication Management
Multisystemic Therapy (MST), 10-18 years of age
Functional Family Therapy (FFT), 11-19 years of age
I'm not sure
Upload Supporting Documents (if applicable)
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of
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
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Submit
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