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About Us
Services
Telemental Health
CORE
DFCS
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Services
School Based Trainings and Groups
School Partners
School Based Referral Form
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Referrals
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Consumer Feedback
Resources
Contact Us
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School Based Referral Form
Client Information
Date of Referral
(Required)
Client's Name
(Required)
First
Last
Date of Birth
(Required)
Grade
(Required)
Insurance Provider
Member ID
Medicaid
(Required)
Yes
No
Gender
(Required)
Male
Female
Other
Race
(Required)
Asian/Pacific Islander
Native American/American Indian
Black
White
Biracial
Other
Hispanic/Latin American
(Required)
Yes
No
Interpreter Needed?
(Required)
Yes
No
Language Spoken
(Required)
Spanish
Mandarin
French
Thai
French Creole
Vietnamese
Hindi
Punjab
Arabic
Turkish
Bengali
Pashto
Urdu
Other
Client School
(Required)
District
(Required)
APS
Fulton
Forsyth
Henry
Clayton
Others
Referral From
(Required)
Social Worker
School Counselor
Parents/Guardian
Hospital
DFCS
Juvenile Court
Others
Referral Contact
(Required)
Phone
(Required)
Email
(Required)
Please confirm you have discussed services with the Legal Guardian prior to making this referral
(Required)
Yes
No
Legal Guardian Name
(Required)
First
Last
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Parent/Guardian Email
(Required)
Does client reside in Georgia?
(Required)
Yes
No
Client diagnosed with Autism Spectrum Disorder?
(Required)
Yes
No
Is the client verbal?
(Required)
Yes
No
Has the client been hospitalized in the the past 6 months?
(Required)
Yes
No
If yes, how many times?
(Required)
In the last 3 months has the client had any suicidal thoughts?
(Required)
Yes
No
Suicide attempts?
(Required)
Yes
No
Is the client currently prescribed medication?
(Required)
Yes
No
Is the client interested in obtaining medication management services through Family Ties?
(Required)
Yes
No
Presenting Issues
Presenting Issues
(Required)
Anxiety
Aggression
Depression
ADHD/ADD
Suicidal Thoughts
Self Harming
Eating Disorder
Foster Care Adjustment Issues
Grief
Trauma
Substance Abuse Concerns
Post Traumatic Stress Disorder (PTSD)
Additional Concerns/Issues