Step Up SOC Referral v1

Step Up System of Care Referral

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 – Step Up Youth Program provides support for youth and caregiver(s) by assisting them with accessing pathways to the right care at the right time.
Is the youth being referred involved with another behavioral health provider?*

YesNo
Please list current Behavioral Health provider information:
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
Diagnosis Information (Please include all recent Mental Health, Substance Abuse, and/or Developmental/IDD Diagnosis):*
*** Please include any known Substance Abuse and screenings ***
Please describe reason/circumstances of referral:*
*** Please include any known Substance Abuse and screenings ***
Insurance/Payer Information*
Insurance/Payer Member ID
Has the parent/guardian been informed and provided consent for this referral to be placed?*

YesNoN/A
Please attach any supporting documents such as Release of Information

Browse Files

Cancelof
Should be Empty:

Step Up System of Care Referral