Referral Form for Adult Behavioral Health and/or Substance Use Services

Referral Form for Adult Behavioral Health and/or Substance Use Services

Referral Form for Adult Behavioral Health and/or Substance Use Services

Information About Individual Being Referred

Age 18 and Older

Please do not use this form for hospital discharge referrals; please call (706) 596-5500 to schedule

Date of Referral*

Name of Referred*

First and Last Name

Date of Birth*

Social Security Number*

If you do not have a Social Security #, type None

Gender*

Prefer Not to Answer

Female

Male

Transgender Female to Male

Transgender Male to Female

Not Listed

Race*

Select

Primary language*

Select

Interpreter Needed*

Yes

Address*

City*

County*

Select or enter value

State*

Zip Code*

Telephone*

Primary Insurance*

Policy Number*

Referring Agency or Organization Information

Referring Agency or Organization*

If None, type None

Relationship to Referred*

If None, type None

Referring Agency Contact Person**

If None, type None

Referring Agency Phone

If None, type None

Referring Agency Address*

If None, type None

Secondary Referring Agency or Organization Information

Referring Agency Secondary Contact

Referring Agency Secondary Phone

Referring Agency Secondary Email Address

Services Requested (choose all that apply)*

Mental Health Services

Addiction/Substance Abuse

Assessment Only

Individual Counseling

Group Counseling

Family Counseling

Community Support Services

Psychiatric/Medication Evaluation

Residential Treatment Services

Reason for agency involvement*

Please provide a detailed description of reason for agency involvement:*

Mental Health or Substance Use Information*

Please provide any additional relevant mental health or substance use information: *

Signature of individual or guardian

Signature of person making referral

Supporting Documentation/Notes

File Upload

Picture ID, Insurance Cards, Social Security Cards and/or any supporting documentation for referral may be uploaded here.

Drag and drop files here or

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