AUTISM RESPITE CARE SERVICES REFERRAL FORM
Atlanta Youth Services | Empowering Youth. Strengthening Families.
Use this form to refer a child or youth to Atlanta Youth Services for Autism Respite Care Services. This first step collects basic referral and eligibility information. Please do not submit a referral without the knowledge of the caregiver or appropriate case contact.
1. REFERRAL SOURCE
REFERRAL DATE (MM/DD/YYYY) *
*
-
Month
-
Day
Year
Date
WHO IS COMPLETING THIS REFERRAL?*
*
Parent or caregiver
DFCS case manager
Adoption assistance or post-adoption professional
CASA or child welfare professional
AYS provider
Other professional or community referral source
REFERRER NAME *
*
First Name
Last Name
RELATIONSHIP TO CHILD OR FAMILY
REFERRING AGENCY OR ORGANIZATION (IF APPLICABLE)
REFERRER EMAIL *
*
example@example.com
REFERRER PHONE *
*
Format: (000) 000-0000.
2. CHILD AND ELIGIBILITY INFORMATION
CHILD'S FULL LEGAL NAME *
*
First Name
Last Name
DATE OF BIRTH (MM/DD/YYYY) *
*
-
Month
-
Day
Year
Date
ELIGIBILITY CATEGORY *
*
Currently in foster care
Adopted from foster care
Other
HAS AN AUTISM DIAGNOSIS BEEN CONFIRMED?*
*
Yes
No
Evaluation pending
Unsure
BRIEFLY EXPLAIN WHY SERVICES ARE BEING REQUESTED *
*
Atlanta Youth Services | 650 Ponce De Leon Avenue, Atlanta, GA 30308 | atlantayouthservices.com
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AUTISM RESPITE CARE SERVICES REFERRAL FORM
Atlanta Youth Services | Empowering Youth. Strengthening Families.
3. SERVICE INFORMATION
DFCS COUNTY CHILD IS ASSIGNED TO *
*
CITY AND COUNTY WHERE SERVICES WILL TAKE PLACE *
*
GENERAL REQUESTED START TIMEFRAME *
*
As soon as possible
Within 30 days
Within 60 days
Future planning
CAREGIVER FULL NAME
First Name
Last Name
CAREGIVER PHONE
Format: (000) 000-0000.
CAREGIVER EMAIL
example@example.com
DOES THE CAREGIVER OR APPROPRIATE CASE CONTACT KNOW THIS REFERRAL IS BEING SUBMITTED?*
*
Yes
No
NEXT STEPS
AYS will review the referral, confirm eligibility documentation, and contact the appropriate caregiver or case contact. Submitting this form does not guarantee immediate provider availability or a specific service start date. * Required field
Atlanta Youth Services | 650 Ponce De Leon Avenue, Atlanta, GA 30308 | atlantayouthservices.com
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