Please complete the form below to submit your referral.  We commit to confirming and making contact with your referral within 48 hours, but usually sooner.  Consumer services are sometimes delayed due to various reasons. Below is a list of the most common scenarios that may cause a delay in consumer services:

  • Inability to make contact with caregivers or consumer to complete assessment.
  • Consumer becomes incarcerated or removed from home shortly after receipt of referral.
  • Parent may not have a working home phone number.

You may also call us at 770.609.6976 to make your referral over the phone. Our regular office hours are Monday – Thursday from 10:00AM to 4:00PM.

Date of Referral:

Your Contact Information



Client/Consumer Information








Insurance Information

Reason for Referral
Please provide a brief summary of client's presenting problems and treatment needs (i.e. depression, anger management, ADHD, etc).