REFERRAL FORM

REFERRAL FORM
120 East Trinity Place l Decatur, GA 30030

Phone (404) 378-2300 l Fax (404) 378-2394
REFERRAL SOURCE (if other than self-referral or caregiver referral)
Date*

MonthDayYear
Date
Name*
Agency
Title
Phone #*
Fax #
E-mail*
example@example.com
CLIENT INFORMATION (please confirm correct name spelling and DOB with client and/or guardian)

First Name:*

	Sex Assigned at Birth	Gender Identity	Sexual Orientation	Pronouns

Name*

First NameLast Name
DOB*
Social Security #
Insurance*
Insurance ID #*
Street Address*
Apartment/Unit #
City*
State*
Zip Code*
County*
Home/Cell Phone*
Work Phone
Email*
example@example.com
Name of School
CAREGIVER #1 (If client is a minor)
Relationship to Minor
Preferred Language
Name

First NameLast Name
DOB
Street Address
Apartment/Unit #
City
State
Zip Code
Home/Cell Phone
Work Phone
Email
example@example.com
CAREGIVER #2
Relationship to Minor
Preferred Language
Name

First NameLast Name
DOB
Street Address
Apartment/Unit #
City
State
Zip Code
Home/Cell Phone
Work Phone
Email
example@example.com
Do the caregivers have full custodial rights to make medical and educational decisions for this child?

YesNo
Is there another parent or caregiver with joint custody we should inform about treatment?

YesNo
Does the client have thoughts of self-harm or of harming others?

YesNo
Does the client have an urgent or critical medical condition?

YesNo
Does the client have a safety threat?

YesNo
REASON FOR REFERRAL?
Requested Services*

CounselingMedication ManagementDiagnostic/AssessmentGroupCrisis/IFI ServiceSubstance UseEMDROther:
A brief summary will expedite assignment to a clinician*

HOW DID YOU HEAR ABOUT US?*

	Online	Social	Outreach

Family/Friend
Family/Friend
Professionals
Professionals
Community
Community
Insurance
Insurance
FOR OFFICE USE ONLY
**Please note: medication management (psychiatric) services are only available for clients receiving counseling services. We are unable to accept referrals for medication management only.

ADMIN1-REFERRAL Revised 5/26/2021
Should be Empty: