APEX Referral for Behavioral Health Services v.4

APEX Referral for Behavioral Health and Substance Abuse Services

In case of emergency call 911 or the Behavioral Health Link at 1-800-715-4225. For hospital discharge referrals call 706-806-1277.
Please Note -- Bridge Health APEX program no longer accepts private/commercial insurance.
Is the youth being referred involved with another behavioral health provider?*

YesNo
Is the family willing to transfer services to Bridge Health?*

YesNo
To receive APEX services with Bridge Health, all therapeutic services must be with Bridge Health. If you would like to speak to a representative of Bridge Health APEX please call 706-806-1260
School System County*

CatoosaChattoogaDadeWalker
Preferred Location for Services*

Fort Oglethorpe Outpatient ClinicSummerville Outpatient ClinicTrenton Outpatient Clinic
School Name*
Current Grade Level*
Information about individual being referred
Referral Date:*

MonthDayYear
Date
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:*

Area CodePhone Number
Electronic Mail Address
example@example.com
Birthdate:*

MonthDayYear
Date
Social Security Number:
Gender*

FemaleMale
Race*

American Indian / Alaskan NativeAsian - OtherBlack / African AmericanMultiracialNative Hawaiian / Other Pacific IslanderOther Single RaceUnknown / Refused to answerWhite / Caucasian
Legal Guardian Name:
***Legal guardian must be present for intake appointment***
Referring Individual/Agency:*

DJJDFCSPardons/ParoleOther
Referring Individuals Name:*
Job Title
Email*
example@example.com
Referring Agency or Organization Name:
Referring Agency/Organization
Referring Agency Phone:

Area CodePhone Number
Contact Person:
Contact Phone:

Area CodePhone Number
Secondary Contact:
Seconday Phone:

Area CodePhone Number
Caseworker:
Caseworker Phone:

Area CodePhone Number
Services Requested (select all that apply)*

Mental Health ServicesAddiction/Substance AbuseCommunity Support ServicesOther
Please describe reason/circumstances of referral:*
*** Please include any known Substance Abuse and screenings ***
Insurance/Payer Information*
*** Currently not accepting private/commercial insurance plans. Please see Private Pay information below ***
Insurance/Payer Member ID
Has the parent/guardian been informed and provided consent for this referral to be placed?*

YesNoN/A
Please bring the following to the initial appointment:
Private Pay Contract:
Please attach any supporting documents such as Release of Information

Browse Files

Cancelof
Should be Empty:

APEX Referral for Behavioral Health and Substance Abuse Services