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New Pathways Youth Services Georgia IFI Intake/Referral Form 
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Email *
Client's Name *
Medicaid ID *
Your medicaid ID should be 12 digits.
Social Security Number *
Provider *
If you do not see your provider listed, we are currently not accepting your insurance.
Age *
DOB mm/dd/year *
Address, City/County, State, Zip *
We are currently only operating in the following counties: Atlanta, Fulton, DeKalb, Clayton, Cobb, Dawson, Forsyth, Banks, Cherokee, Hall, Lumpkin, Pickens and Gwinnett. If your county is not listed, you are located outside of our service area.
Gender *
Race *
Legal Guardian's Name, Email and Phone Number *
Referring Agency/Worker & Contact #
Which school does the client attend? *
Who is the client's primary care physician? *
Which day of the week would be the best day to contact you? (check all that apply)
 *
Required
When would be the best time to contact you? (check all that apply)
 *
Required
Why was your family referred for services?
 *
How long have you/your family been having these issues?
 *
Does the client currently have a therapist? If so, please provide the name of the therapist, name of the practice and how long they have been seeing them. *
Are you currently taking any mental/physical health medications? If so, what are they? *
Have you received any mental health services in the past, or is there an existing diagnosis?
 *
Are there any issues threatening to send the client out of the home for psychiatric hospitalization, homelessness, incarceration, or away from those who provide their support?
 *
Intensive family Intervention Checklist (Client must meet at least 2 to qualify for services):
Your Name/Email *
How was this contact made? *
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