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:
MM
/
DD
/
YYYY
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
If this person is being referred from a Georgia HOPE School-Based Mental Health Program site, please select the school she/he attends:
Information About the Person Making this Referral:
Your First Name:
Your answer
Your Last Name:
Your answer
Your Phone Number:
Your answer
Alternate Phone Numbers:
Your answer
Your Email Address:
Your answer
Your Relationship to the Person being Referred:
Please list the specific school, doctor's office, agency, or organization you are referring from here (if applicable):
Your answer
Reason for Referral:
Your answer
Services you think may be helpful to this person (select all that apply):
Any additional information you'd like us to know:
Your answer
Additional Referrals:
If you'd like to make additional referrals for a child or adult who lives in this SAME HOUSEHOLD, please list each person's Name, Gender, Date of Birth and Social Security Number below.

Please do not include individuals who live in a SEPARATE household here. Only list children and adults here who have the same address and phone number as the original person being referred.

Additional Referral Information:
Your answer
A copy of your responses will be emailed to the address you provided.
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