Reconciliation Movement Referral
This referral form is for our Hood Recovery Program and our community partners that have participants in need of risks and needs, mental health or substance abuse services.  If you have any questions about Hood Recovery services call 678-561-3091 for general services. Go to for more info!
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Email *
Person/Agency Making the Referral: *
First and last name
Person/Agency Making the Referral Contact Information: *
Email Address & Phone Number
Relationship to the Referee: *
Reconciliation Movement "Reconcile with Faith, Hope, Knowledge, & Unity"
Referee First and Last Name: *
Referee Date of Birth: *
Referee Age: *
Gender Identity *
Race & Ethnicity *
Relationship Status *
Employment Status *
Preferred Language *
Referee Email: *
Referee Phone Number: *
Referee Address: *
Referee County: *
Referee Living Status: *
Services Needed: *
Does Referee Have Medical Insurance: *
If Referee Has Medical Insurance, What Type?: *
Reason for Referral: *
A copy of your responses will be emailed to the address you provided.
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