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

 
 
mm/dd/yyyy
 

First and Last Name

 
 
 
mm/dd/yyyy
 

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

 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 

 

Referring Agency or Organization Information

 

If None, type None

 
 

If None, type None

 

If None, type None

 
 

If None, type None

 

If None, type None

 

 

Secondary Referring Agency or Organization Information

 
 
 
 
 

 
 

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

 
 

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

 
 
 
 
 
 

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

Drop your files here