Referral for Services by Agency

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This form is for partner agencies (Doctor office, school, DFCS, etc.) to securely submit referrals on behalf of families for counseling services. If you are an individual seeking counseling or are an existing client, call 706-204-9303.

If the client/family is experiencing a mental health emergency, call 911 or direct them to the nearest emergency room.

The client/family will be contacted within 3 business days after completing this form.

Identified Client Name (First and Last)
*

Legal Guardian Name (First and Last) ~ if Identified Client is a minor (or Foster Parent name if client is in foster care)

Client (or Legal Guardian, or Foster Parent) Contact Phone Number (XXX) XXX-XXXX
*

Client's Date of Birth
*

YYYY

Client's PRIMARY Insurance
*

Aetna

Amerigroup

Anthem (Blue Cross / Blue Sheild)

CareSource

Cigna / Evernorth

Medicaid (Georgia)

PeachCare for Kids

United Healthcare

None

[I don't know. / Unsure]

Other:

Select ALL mental health reasons for the referral

Academic Issues

Behavior Problems (at school and/or home)

Depression

Family / Peer Issues

Grief / Loss (Example: Death of family or loved one)

Major Life Transition

Phobia

Traumatic Experience (Example: Abuse, Victim of Crime, Traumatic Event)

[I don't know. / Unsure]

Other:

YOUR Name (First and Last)
*

YOUR Agency Type
*

YOUR Email Address
*

YOUR Contact Phone Number (XXX) XXX-XXXX
*

Do you plan to submit supporting documentation after finishing this form?
*

Yes ~ (click the link in the 'Supporting Documentation' box below to send secure email)

Supporting Documentation (Optional)

If you wish to submit supporting documentation (such as your agency's referral form, your agency's records), or any additional information that will assist in our delivery of services, please submit the information securely by clicking here. You will be directed to a secure email platform where you can add attachments. Please include 'Referral from [YOUR Name]' in the Header and the Client's name in the BODY of the email.

Remember to return to this form and click SUBMIT below!

Form Submission

This form is NOT for instances of a mental health emergency. If the client is experiencing a mental health crisis/emergency, call 911 or direct them to the nearest emergency room.

Submitting this form is an inquiry and does not guarantee that the client will receive an appointment. We will contact the client (or legal guardian) within 3 business days to obtain further information.

Submit

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