Main Address: 101 Devant St., Ste. 702, Fayetteville, GA 30214
Satellite Address: 2245 Godby Rd., Ste. 107 College Park, GA 30349
Phone-(770) 460-0970 Fax (866) 758-5731
Outpatient Referral Form
Referral Source (circle one):
School DJJ Juv. Court Other (please specify) ______
County: ______Date of referral: ______
Person Making Referral: ______Telephone number: ______
Individual Therapy Family Therapy Other Services______
Client/Child’s name: ______
Address: ______
City: ______Zip: ______
Phone: ______
Social Security No: ______(required) DOB: ______
Gender: Male Female Race: ______
Medicaid/Peachcare: Yes No M/P number: ______
(If the family does not have Medicaid number, please indicate source of payment for services), Some county cases with no Medicaid on a sliding scale fee.
Insurance: ______Insurance number: ______
Child’s school: ______Grade: ______
Child lives with: Mother Father Both Parents Maternal Grandparents
Paternal Grandparents Legal Guardian: Name______
Is client/child on medications?
No Yes If yes, please list:______
Most recent DSM IV diagnosis (required DSM codes with description and attach current evaluation): Axis I______Axis II______Axis III______Axis IV______Axis V_____
Why is the client/child being referred to the program?
Oppositional Run Away Drug Use Depression Truancy
Sexual Abuse Physical Abuse Mental Health Issues Sexual Perpetrator
DFACS Involvement Probation Violation ADHD Other: ______
What outcome would you like to see for his/her participation? ______
______
Name of Case Worker/Probation Officer:
Phone: ______Fax: ______
Email: ______ (we will email you weekly updates on the case)