Referral Form for Child & Adolescent Behavioral Health and/or Substance Use Services

Information About Individual Being Referred

Age 17 and Younger

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

Date of Referral

mm/dd/yyyy

Name of Referred

First and Last Name

Date of Birth

mm/dd/yyyy

Social Security Number

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

Race

Primary language

Interpreter Needed

Yes

Address

City

County

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

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

File Upload

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

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