JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Reconciliation Movement Referral
This referral form is for our Hood Recovery Program and our community partners that have participants in need of risks and needs, mental health or substance abuse services. If you have any questions about Hood Recovery services call 678-561-3091 for general services. Go to
www.hoodrecovery.org
for more info!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Person/Agency Making the Referral:
*
First and last name
Your answer
Person/Agency Making the Referral Contact Information:
*
Email Address & Phone Number
Your answer
Relationship to the Referee:
*
Self
Family
Friend
Case Manager
Probation Officer
Other:
Reconciliation Movement "Reconcile with Faith, Hope, Knowledge, & Unity"
Referee First and Last Name:
*
Your answer
Referee Date of Birth:
*
MM
/
DD
/
YYYY
Referee Age:
*
Your answer
Gender Identity
*
Your answer
Race & Ethnicity
*
Choose
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Race or Ethnicity Not Listed
Relationship Status
*
Choose
Single
Married
Separated
Divorced
Widowed
Employment Status
*
Unemployed
Full-Time
Part-Time
Self-Employed
Other:
Preferred Language
*
Choose
English
Spanish
Other
Referee Email:
*
Your answer
Referee Phone Number:
*
Your answer
Referee Address:
*
Your answer
Referee County:
*
Clayton
Gwinnett
Fulton
Dekalb
Henry
Rockdale
Newton
Jasper
Other:
Referee Living Status:
*
Lives on their own (rents/owns a house)
Lives with family/friend
In a homeless shelter
Homeless
Incarcerated (Hood Recovery Program)
Other:
Services Needed:
*
Mental Health
Substance Abuse
Hood Recovery Program
Wrap Around Services (Housing Brief Intervention) (HTNH ONLY)
Risk and Needs Assessment (HTNH ONLY)
Other:
Required
Does Referee Have Medical Insurance:
*
Yes
No
Pending
If Referee Has Medical Insurance, What Type?:
*
N/A
Medicaid (Non-CMO & PeachCare for Kids)
CareSource
PeachState
AmeriGroup
BCBS
Aetna
Cigna
United HealthCare
Other:
Reason for Referral:
*
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Mental Wellness Reconciliation, Inc.
Report Abuse
Forms
