Georgia HOPE Referral Form
Thank you for your interest in making a referral to Georgia HOPE!

Anyone can refer themselves or someone else to services with us. To do so, simply complete the below form.

Please note that information collected on our online referral form is protected with end-to-end encryption and meets HIPAA compliant guidelines for transferring protected health information.

We ask that you begin by providing your email address so that we can send you a copy of your referral.

Email address *
Information about the Person Being Referred:
I am referring a *
The person being referred lives in this county: *
Person's First Name: *
Your answer
Person's Preferred Name (if different than above):
Your answer
Person's Last Name: *
Your answer
Person's Date of Birth: *
Person's Social Security Number *
Your answer
If the person is a child, please list their caregiver's name:
Your answer
Caregiver's Relationship to the Child (if applicable):
Phone Number of the Person being Referred: *
Your answer
Alternate Phone Number(s):
Your answer
Street Address Where Person Currently Resides: *
Your answer
City, State: *
Your answer
Zip Code: *
Your answer
Person's Gender: *
Person's Race/Ethnicity: *
Person's Primary Language: *
Communication Needs (please specify):
Your answer
What School does the Person Attend? (if applicable):
Your answer
Person's Insurance Provider: *
Insurance Number (if known)
Your answer
Check if this person is being referred by the GA Dept. of Juvenile Justice, and is thus eligible for per diem funds
Is this person being referred from a Georgia HOPE School Based Mental Health Program site?
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