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User Name Password
Referral Form
Referral Source (check one)
DFCS DJJ
Juvenile Court Other (please specify)
Has the child been evaluated?
Yes No
Is there a pending evaluation scheduled and when?
Yes No
Country
Date of referral(dd/mm/yyyy)
Child’s name
Address
City
Zip
Phone
Social Security No*
Date Of Birth(dd/mm/yyyy)
Gender
Male Female
Race
Medicaid/Peachcare
Yes No
M/P number
(If the family does not have Medicaid number, please indicate source of payment for services), Fulton County cases with no Medicaid are acceptable
Child’s school
Grade
Child lives with
Mother Father
Both Parents Maternal Grandparents
Paternal Grandparents Legal Guardian
Name
Is child on medications?
Yes No
Most recent DSM IV diagnosis
DSM Code
Current Evaluation
Axis I
Axis II
Axis III
Axis IV
Axis V
Why is the child being referred to the program?
Oppositional Run Away
Drug Use Depression
Truancy Sexual Promiscuity
Physical Abuse Mental Health Issues
Sexual Perpetrator    
DFCS Involvement Probation Violation ADHD Other
What outcome would you like to see for his/her participation?
   
Case Worker/Probation Officer
Phone
Fax
Email
(we will email you weekly updates on the case)
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