EMERGE

EMERGE OFFICE NUMBER: 706-596-5500 ext 5520

Referring Agency or Organization Information

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

Unknown

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

Yes

Unknown

Ethnicity

Hispanic/Latino Origin

Non Hispanic

Unknown/Refused

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

Yes

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

Yes

Is the Individual prescribed any medications?

If Yes, please list medications

File Upload

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

Drop your files here

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

Referral Form for EMERGE