Referral for Behavioral Health Services

attention:

For Self referrals we offer open access at our four outpatient clinics located in Fort Oglethorpe, LaFayette, Summerville, and Trenton.
Interagency Referral for Behavioral Health and Substance Abuse Services

In case of emergency call 911 or the Behavioral Health Link at 1-800-715-4225. For hospital discharge referrals call 706-806-1277.
Preferred Location for Services *

Fort Oglethorpe Outpatient Clinic LaFayette Outpatient Clinic Summerville Outpatient Clinic Trenton Outpatient Clinic
Information about individual being referred
Referral Date: *

Month Day Year
Date
Name: *

First Name Last Name

Address: *

Phone Number: *

Area Code Phone Number
Electronic Mail Address
example@example.com
Birthdate: *

Month Day Year
Date
Social Security Number:
Legal Guardian Name:
***Legal guardian must be present for intake appointment***
Referring Individual/Agency: *

DJJ DFCS Pardons/Parole
Referring Individuals Name:
Referring Agency or Organization:
Referring Agency/Organization
Referring Agency Phone:

Area Code Phone Number
Contact Person:
Contact Phone:

Area Code Phone Number
Secondary Contact:
Seconday Phone:

Area Code Phone Number
Caseworker:
Caseworker Phone:

Area Code Phone Number
Services Requested (select all that apply) *

Mental Health Services Addiction/Substance Abuse Community Support Services
Please describe reason/circumstances of referral: *
*** Please include any known Substance Abuse and screenings ***
Insurance/Payer Information *
*** Currently not accepting private/commercial insurance plans. Please see Private Pay information below ***
Insurance/Payer Member ID
Please bring the following to the initial appointment:
Private Pay Contract:
Please attach any supporting documents such as Release of Information

Browse Files

Cancel of
Should be Empty:

attention: