EMERGE

Referral Form for EMERGE

EMERGE OFFICE NUMBER: 706-596-5500 ext 5520

Referring Agency or Organization Information

Date of Referral*

Referring Department/ Agency*

Referring Agency Contact Person*

First and Last Name of Contact Person referring individual. If None, type None

Referring Agency Phone*

If None, type None

Phone

Is this referral from an outside agency/ provider?*

Yes

No

Unknown

Has this provider or organization referred other potential clients to New Horizons in the past?

Yes

No

Unknown

Name of Referred (Client being referred)*

Client Referred DOB*

Ethnicity*

Hispanic/Latino Origin

Non Hispanic

Unknown/Refused

Gender*

Female

Male

Client being referred Phone:*

Phone

Address*

City*

State*

Zip Code*

County*

Select or enter value

Living Situation*

Residential

Family

Foster Care

Other

School Attending*

Has the individual been formally diagnosed with a mental health condition?*

Yes

No

Diagnosis*

Is the individual using other services provided by New Horizons Behavioral Health?*

Yes

No

Is the Individual prescribed any medications?*

If Yes, please list medications

Parent/Guardian/Custodian*

Parent/Guardian/Custodian Cell/Home Number:*

Phone

Parent/Guardian/Custodian Work Number:

Phone

Parent/Guardian/Custodian Home Number:

Phone

Parent/Guardian/Custodian Email:*

Parent/Guardian/Custodian Address:*

Parent/Guardian/Custodian City:*

Parent/Guardian/Custodian State:*

Parent/Guardian/Custodian Zip:*

Parent/Guardian/Custodian County:*

Please describe reason for referral to EMERGE:*

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

VISIT US AT 2100 COMER AVE, COLUMBUS, GA 31904

Visit our website at www.nhbh.org for more information or

EMERGE OFFICE NUMBER (706) 596-5500

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