DFCS PUP Service Referral Form

DFCS PUP Service Referral Form
If you are requesting services to be paid for by insurance (Amerigroup), you do not need to complete this form. Instead, please only complete our DFCS Amerigroup Service Referral Form.

To submit this form, you will need a valid DFCS Service Authorization to upload at the end.

For questions or problems completing this form, please give us a call and leave a voicemail at 770-457-5577. You may also email us at Referrals@AtantaPsychological.com with any questions.
Today's Date*

MonthDayYear
Date
Date on Service Authorization (if different from above)

MonthDayYear
Date
Are you requesting a specific clinician?
Indicating a preference may limit scheduling availability.
DFCS Employee Information
Name of DFCS employee or individual making this referral:*

First NameLast Name
Title*
Email*
example@dhs.ga.gov
Phone number*

Area CodePhone Number
DFCS Supervisor Name (if different from above)

First NameLast Name
Supervisor Email
example@dhs.ga.gov
Supervisor Phone Number

Area CodePhone Number
Is the client aware of this referral?*

YesNo
DFCS county responsible for this referral*
How many clients are being referred on this service authorization or request?*
Contact us us if more than 4 individuals on the Service Authorization.
Client Information
(1) Client Name*

First NameLast Name
(1) Client Date of Birth*

MonthDayYear
Date
(1) Services represented on the Service Authorization (check all that apply)*

Psychological Evaluation- 54ADomestic Violence Assessment- 29AParental Fitness Assessment- 29CPsychosexual Evaluation- 29DSubstance Abuse Assessment- 29ETrauma Assessment- 29FBonding/Attachment Assessment- 29HCounseling - Licensed 50ANeuropsychological Evaluation- 54B (must be court ordered and pre-approved)Other
(1) Is this client in DFCS custody? *
(1) Client Gender*
(i.e., male, female, trans, etc.)
(1) Race*
(i.e., Client's ethnicity or race)
For this client (1), check only the concerns that apply:

May require someone to read test items to them.Speaks Spanish onlyVision ImpairmentHearing ImpairmentOther
(1) Current Placement
(1) Person to contact for scheduling appointment (if not the client)

First NameLast Name
(1) Relationship to client
(1) Best phone number for scheduling

Area CodePhone Number
(1) Best email for scheduling
example@example.com
(1) Please include any special considerations or concerns for this client in the space below.

DFCS Consent Agreement and Service Authorization Upload
If any of the clients listed above are in the custody of DFCS, by signing and submitting this form, you (as their DFCS case manager and legal guardian), are also authorizing the following individuals to sign the Atlanta Psychological Services legal and consent forms to provide the requested services:
- The foster child's foster parent
- The foster parent case manager
- The foster child's group home staff member
- The foster child's DFCS transporter
You are also certifying that all information provided in this form is true and correct to the best of your knowledge.

For questions or problems completing this form, please give us a call and leave a voicemail at 770-457-5577.

You may also email us at Referrals@AtantaPsychological.com with any questions.
For identification verification, please upload a photo of your work ID:
DFCS Case Manager / Supervisor Signature*

Clear
Please upload the Service Authorization for this referral*

Browse Files
The services on the Service Authorization should match the service(s) requested in this request. Cancelof
Please let us know if you have any additional considerations or instructions for this request.
Thank you for your referral!
Should be Empty: