DFCS Services Referral

Referral Source Name of referring person Date of Referral: County Cherokee Cobb Clayton Dekalb Douglas Forsyth Fulton Gwinnett Hall Henry Rockdale Agency DFCS School BHL PRTF Family Probation DJJ Other Phone Mobile Email Fax Preferred Contact Method Phone Mobile Email Supervisor: Supervisor Phone Is Client aware referral is being made Yes No Client Information Client Name: Language Spoken DOB: Gender: Male Female Ethnicity: Client’s School: Current Grade Level: Current Placement: Biological Parent Foster Placement Group Home Other Other Legal Guardians Name: Current Address: Phone Number: Mobile Mental Health Diagnosis: Medications: Medicaid #: Social Security Number#: Type: Medicaid Peachstate/Cenpatico Amerigroup WellCare *Uninsured *For uninsured , families must apply for Peachcare before services can be provided- www.peachcare.org Has client had a **psychological evaluation in the past 12 months? Yes No Unknown Has client had a **psychiatric evaluation in the past 12 months? Yes No Unknown Behavior in the last 6 months: Runaway Physical Aggression Suicidal Ideation / Attempt Verbal Aggression Defiance Legal Involvement Deprived Sexual Acting Out Self-Harming Behaviors Other Other Presenting Problems: Legal Open/Pending Court Case Yes No Court Date: Court Part Name County: Phone DFCS approval for services Yes No DFCS Involvement: *Yes No *If child is in the custody of DFCS please complete consent form Type in the correct information in the parenthesis I (your name), the case worker for (child's name) as guardian of said consumer, authorize the Foster Parent/FP Case Manager (case managers name) For (child's name) the authority to sign the Family Ties, Inc. legal and consent form’s authorizing CORE services.<br /> Caseworker: Telephone #: Electronically Signed Signed Date **Please attach Please attach psychological/psychiatric or any supporting documents

Rate Sheet for SHINES Downloadable Referral Form Download CCFA referral Click HERE to Download Brochure Download Information Flyer

*Please Ensure All Shines Authorizations Are Attached To This Referral*

Complete On-line or Fax to: 678-460-0350

Email: DFCSreferrals@Familytiesinc.com