Clinical Client Referral Form V2024

  • Client Referral Form

    Frances-Bunzl Clinical Services and Horwitz-Zusman Child & Family Center
  • Are you requesting services for yourself or someone else?*

  • Please note: If you are not the parent, legal guardian, or power of attorney for the client seeking services, kindly note that the client must personally submit a request for services. Please ensure that the client returns to this form, emails us at therapy@jfcsatl.org, or contacts our Clinical Referral Line at 770-677-9474.
    We appreciate your cooperation in this matter and look forward to assisting the client on their journey to well-being.

  • What is your relationship to the client?*

  • The information below will be used to register you as a delegate on our client portal. Please note that minors will not have access to the portal until they reach the age of 18. To ensure successful registration, please provide your correct email address, phone number, and date of birth.
  • Date of Birth:*
     - -
  • Format: (000) 000-0000.
  • What is your relationship to the client?*
  • Date of Birth:*
     - -
  • Format: (000) 000-0000.

  • Client Contact information

  • Client Date of Birth*
     - -
  • Client sex*
  • Preferred Language*
  • Format: (000) 000-0000.
  • Preferred method of contact*
  • Is it OK to leave message on voicemail?*

  • Background information

  • How did you hear about our therapy service?*
  • Have you ever received therapy or counseling before?*

  • Reason for Seeking Services

  • Desired Services (Check all that apply):*
  • Are you interested in group therapy programs (e.g., Anxiety, Relationship, Bereavement)?*
  • Spouse Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Risk Assessment Brief Questionnaire

  • Have you had thoughts of harming yourself or ending your life in the past two weeks?*
  • In the past month, have you engaged in any self-harming behaviors, such as cutting or scratching yourself?*
  • Are you currently using any substances, including alcohol or drugs, to cope with stress, anxiety, or other emotional difficulties?*

  • Note: JF&CS Atlanta does not offer crisis services.

    If you're in immediate danger or need urgent support, please call 911 or go to your nearest emergency room.

    For assistance specifically related to mental health support in the state of Georgia, you can contact the Georgia Crisis and Access Line at 1-800-715-4225. They offer 24/7 support and can provide information on local resources.

    You can also call or text the National Helpline 988.

    In the Atlanta area, Individuals experiencing urgent behavioral health issues may seek help at Grady’s Emergency Department, which has around-the-clock behavioral health staff. The emergency department is located at 80 Jesse Hill Jr. Drive, SE.

  • Availability, preferences

  • Do you prefer in-person therapy or online/teletherapy sessions?*
  • Which location do you prefer?*

  • Additional information

  • Insurance Information

  • Note: The following services do not accept insurance: Group Therapy, Art Therapy, Executive Function Coaching, Parent Coaching, Psychoeducation Testing, Neurology/ADHD Testing

  • Are you wanting to use insurance for clinical services?*
  • Insurance Carrier (Select all that apply)*

  • Note: We do not accept Medicaid, CareSource, Ambetter PeachState Health Care, PeachCare for Kids, Kaiser Permanente, or Wellcare of Georgia.

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  • Effective date*
     - -
  • Policy Holder (Guarantor) DOB*
     - -
  • Format: (000) 000-0000.
  • Secondary Insurance Effective date
     - -
  • Secondary Insurance Policy Holder Date of Birth
     - -
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  • Private Pay

  • Are you interested in Private Pay fees for services?*

  • Emergency contact

  • Format: (000) 000-0000.

  • Consent and agreement

  • Should be Empty: