REFERRAL FORM

REFERRAL FORM
120 East Trinity Place l Decatur, GA 30030

Phone (404) 378-2300 l Fax (404) 378-2394
REFERRAL SOURCE (if other than self-referral or caregiver referral)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name
Agency
Title
Phone #
Format: (000) 000-0000.
Fax #
E-mail
example@example.com
CLIENT INFORMATION (please confirm correct name spelling and DOB with client and/or guardian)
Name

First NameLast Name

How do you identify? (Please select an option from each section)

Rows	Sex Assigned at Birth	Gender Identity	Sexual Orientation	Pronouns

DOB
Social Security #
Insurance
Insurance ID #
Street Address
Apartment/Unit #
City
State
Zip Code
County
Home/Cell Phone of Parent (if under 18 years old)
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
example@example.com
Name of School
CAREGIVER #1 (If client is a minor)
Relationship to Minor
Preferred Language
Name

First NameLast Name
DOB
Street Address
Apartment/Unit #
City
State
Zip Code
Home/Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
example@example.com
CAREGIVER #2
Relationship to Minor
Preferred Language
Name

First NameLast Name
DOB
Street Address
Apartment/Unit #
City
State
Zip Code
Home/Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
example@example.com
Do the caregivers have full custodial rights to make medical and educational decisions for this child?
Is there another parent or caregiver with joint custody we should inform about treatment?
Does the client have thoughts of self-harm or of harming others?
Does the client have an urgent or critical medical condition?
Does the client have a safety threat?
REASON FOR REFERRAL?
Requested Services
A brief summary will expedite assignment to a clinician

HOW DID YOU HEAR ABOUT US?

Rows	Online	Social	Outreach

Family/Friend
Family/Friend
Professionals
Professionals
Community
Community
Insurance
Insurance
FOR OFFICE USE ONLY
**Please note: medication management (psychiatric) services are only available for clients receiving counseling services. We are unable to accept referrals for medication management only.

ADMIN1-REFERRAL Revised 5/26/2021
Should be Empty: