Assertive Community Treatment (ACT) Referral Form
Agency that will receive ACT Referral: Cobb/Douglas
Clinical ExclusionsIndividuals cannot have a primary diagnosis of developmental disability, autism, organic mental disorder, substance-related disorder or traumatic brain injury and/or primary Axis II diagnosis.
Enter the following information for AT LEAST the last 3 inpatient hospitalizations occurring in the last 365 days (enter more if applicable):
For External referrals...Please fax any accompanying documents (ie, Assessments, Notes) to the Cobb/Douglas ACT Team @ 770-948-6147