Atlanta Youth Services - ARCS Referral Form

Atlanta Youth Services - ARCS Referral Form

Submit one referral per child or young adult and provide the caregiver details for follow-up intake and consent.
Section 1: Referral Source & Eligibility

Referral source and eligibility details
Referral date

MonthDayYear
Date
Request type
Referring person/agency
Referrer phone
Please enter a valid phone number.Format: (000) 000-0000.
SHINES case/referral ID
Case manager/contact
Case manager email
example@example.com
Case manager phone
Please enter a valid phone number.Format: (000) 000-0000.
Eligibility
DFCS region
County
Section 2: Child / Youth & Caregiver Information
Child/youth full name

First NameLast Name
Date of birth

MonthDayYear
Age
Caregiver name

First NameLast Name
Caregiver relationship
Caregiver email
example@example.com
Caregiver phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred language
Service address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Service county
Additional information
Section 3: Requested Respite Services & Provider Match

Requested respite services and provider preferences
Requested start date

MonthDayYear
Date
Dates/days/times requested
Schedule
Total hours requested
Service location
Provider gender preference

Other
Pet comfort
Other provider preferences
Additional staffing may be needed
If yes, explain
AYS providers do not transport children.
Section 4: Child Profile, Safety Needs & Reason for Referral
Communication/AAC/preferred interaction
Important behaviors, triggers, supervision, or safety risks
Other safety concern
Details/what helps
Health, medication, allergy, feeding, seizure, mobility, or personal-care needs
Family goals/reason respite is requested now
Section 5: Referral Confirmation & Supporting Documents
Upload autism diagnostic record

Cancelof
Upload current safety/behavior plan

Cancelof
Submitted by

First NameLast Name
Title
Signature
Signature date

MonthDayYear
Date
Referral Confirmation
Should be Empty:

Atlanta Youth Services - ARCS Referral Form

Section 1: Referral Source & Eligibility

Section 2: Child / Youth & Caregiver Information

Section 3: Requested Respite Services & Provider Match

Section 4: Child Profile, Safety Needs & Reason for Referral

Section 5: Referral Confirmation & Supporting Documents