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)
CLIENT INFORMATION (please confirm correct name spelling and DOB with client and/or guardian)
CAREGIVER #1 (If client is a minor)
**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