Referral for Behavioral Health Services

Attention:

For Self referrals we offer open access at our four outpatient clinics located in Fort Oglethorpe, 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 ClinicSummerville Outpatient ClinicTrenton Outpatient Clinic
Information about individual being referred
Referral Date:*

MonthDayYear
Date
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:*

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

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

DJJDFCSPardons/ParoleOther
Referring Individuals Name:
Referring Agency or Organization:
Referring Agency/Organization
Referring Agency Phone:

Area CodePhone Number
Contact Person:
Contact Phone:

Area CodePhone Number
Secondary Contact:
Seconday Phone:

Area CodePhone Number
Caseworker:
Caseworker Phone:

Area CodePhone Number
Services Requested (select all that apply)*

Mental Health ServicesAddiction/Substance AbuseCommunity Support ServicesOther
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 attach any supporting documents such as Release of Information

Browse Files

Cancelof
Documents Required for Enrollment:
Financial Payment Plan Coverages:
Should be Empty:

Attention:

Interagency Referral for Behavioral Health and Substance Abuse Services