DFCS Service Request Form
Thank you for your interest in submitting a Service Authorization to Georgia HOPE (Family & Children First).

Please complete the form below and we will be in touch with you shortly to confirm or decline this service request.

Many thanks,
Georgia HOPE (Family & Children First)


*Please note: If you suspect that this child/adult has a mental health or substance abuse concern and they also receive Georgia Medicaid (Amerigroup, CareSource, Peachstate/Cenpatico, Wellcare, Peachcare), consider submitting a referral for Georgia HOPE's Core Services instead, as this will save DFCS funds. You can submit a Core referral here: https://goo.gl/forms/RMAgAJSHE3ZZO9Jj2

Your First & Last Name:
Your answer
Your Email Address:
Your answer
Which county DFCS office is requesting this service?
If your county is not listed in the dropdown list below, please contact us at info@gahope.org, rather than completing this form.
If known, what county does this child or family currently reside in?
Your answer
What service(s) are you requesting for this case? (select all that apply)
Required
What date would you ideally like services to begin?
MM
/
DD
/
YYYY
Is there any additional information we need to be aware of?
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Georgia HOPE. Report Abuse - Terms of Service - Additional Terms