• Atlanta Youth Services Autism Respite Care Services Intake and Referral

    Complete the referral, intake, and service planning details, then upload supporting documents and sign to submit.

  • Referral

  • Relationship to child*
  • Format: (000) 000-0000.
  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Intake

  • Is the primary caregiver the same person as the referrer?*
  • Format: (000) 000-0000.
  • Contact Information
  • Format: (000) 000-0000.
  • Emergency contact
  • Format: (000) 000-0000.

  • Service Planning

  • ARCS services have a minimum of 4 hours.
  • Requested Start Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Requested Days
  • Monday Start Time
  • Monday End Time
  • Tuesday Start Time
  • Tuesday End Time
  • Wednesday Start Time
  • Wednesday End Time
  • Thursday Start Time
  • Thursday End Time
  • Friday Start Time
  • Friday End Time
  • Saturday Start Time
  • Saturday End Time
  • Sunday Start Time
  • Sunday End Time
  • Schedule Flexibility*

  • Document Upload

  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Referrer Signature

  • Date signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: