CORE/Medicaid Referral Form
Date: *
MM
/
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Caseworker (or name of referring individual): *
Telephone/Fax#: *
County office (or referring agency): *
Email Address: *
Referral Source: *
Required
Service to be provided: *
Required
Reasons for referral: *
Required
Additional comments: *
Name of Primary Caregiver: *
Email: *
Contact Number: *
Address: *
City/Zip: *
Name of Consumer: *
School/Grade: *
Medicaid#: *
Medical Plan: *
DOB: *
MM
/
DD
/
YYYY
Has Consumer been diagnosed or has a suspected Mental Health or Substance Abuse Disorders? *
Please fax Psychological and/or Psychiatric Assessments to: 770-918-8800
Check all that apply: *
Required
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