CORE/Medicaid Referral Form
* Required
Date:
*
MM
/
DD
/
YYYY
Caseworker (or name of referring individual):
*
Your answer
Telephone/Fax#:
*
Your answer
County office (or referring agency):
*
Your answer
Email Address:
*
Your answer
Referral Source:
*
DFCS
Health Department/Hospital
DJJ
MH/MR/SA
Juvenile/Family Court
Law Enforcement
Community Agency
School
Other:
Required
Service to be provided:
*
Group Counseling
Intensive Family Intervention
Community Support Services
Individual/Family Therapy
Juvenile/Family Court
Law Enforcement
Community Agency
School
Other:
Required
Reasons for referral:
*
Child Abuse
Child Neglect
Sexual Abuse
Reunification Plan
Family Therapy
Individual Therapy
Anger Management
Placement Support
Life Skills Training
Academic Support /Truancy
Juvenile Delinquency
Behavioral Management
Run Away Behavior
Substance Abuse
Crisis Intervention
Teen Pregnancy
Gang Involvement
Other:
Required
Additional comments:
*
Your answer
Name of Primary Caregiver:
*
Your answer
Email:
*
Your answer
Contact Number:
*
Your answer
Address:
*
Your answer
City/Zip:
*
Your answer
Name of Consumer:
*
Your answer
School/Grade:
*
Your answer
Medicaid#:
*
Your answer
Medical Plan:
*
Medicaid
Amerigroup
Well Care
Peach State
None
DOB:
*
MM
/
DD
/
YYYY
Has Consumer been diagnosed or has a suspected Mental Health or Substance Abuse Disorders?
*
Yes
No
Please fax Psychological and/or Psychiatric Assessments to: 770-918-8800
Check all that apply:
*
ADHD
Conduct Disorder
Oppositional Disorder
Learning Disability
Mental Retardation
Bipolar/Manic Disorders
Depression
Substance Abuse/Dependency
Schizophrenia or other Psychotic Disorders
Other:
Required
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