Home
About Us
About Family Ties
Director’s Message
Programs
DFCS Services
Mental Health Services
Private Consulting
Information
Release of Information
Consumer Rights
Resources
Hippa Form
Newsletter
Referrals
DFCS Services Referral
Mental Health Referral
Staff Directory
Contact Us
Feedback
Consumer Complaint Form
Consumer Services Satisfaction Survey
Stakeholder Satisfaction Survey
Mental Health 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
Download Referral
Click
HERE
to Download Brochure
Download Flyer:
English
-
Spanish
