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  • 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.

     

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  • DFCS Employee Information

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  • Client Information

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    • Client 2 (if applicable) 
    • Client (2) Information

       
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    • *Only add the best contact for scheduling if different than Client 1.

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    • Client 3 (if applicable) 
    • Client (3) Information

       
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    • *Only add the best contact for scheduling if different than Client 1.

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    • Client 4 (if applicable) 
    • Client (4) Information

       
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    • *Only add the best contact for scheduling if different than Client 1.

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    • 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.

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    • Thank you for your referral!

       
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