Name of Consumer:



*Referral will not be processed without one of these forms of verification.*Referral will not be processed without one of these forms of verification.

Type of Medicaid:	Wellcare/Megellan	Amerigroup	Peachstate/Cenpatico	DFCS/DJJ
			Unknown
Referring Source:
Check One:	Family Member/Guardian	Group Home	DFCS	DJJ
	School	Community Agency

Address (City,State,Zip Code):
Admission Information:
Service Requested:

Consumer at risk of placement disruption.	Yes   No
Reunification is the goal for consumer.	Yes   No
Consumer has a known or suspected mental illness diagnosis.	Yes   No
Consumer has a known or suspected substance abuse diagnosis.	Yes   No
Consumer has been diagnosed with Mental Retardation, Autism, Developmental Disabilities, Organic Mental Disorders, or Traumatic Brain Injury.	Yes   No
Consumer has insufficient or severely limited resources or skills necessary to cope with immediate crisis.	Yes   No
Consumer and/or family issues are unmanageable in traditional outpatient treatment.	Yes   No
Consumer requires intensive coordinated clinical and supportive intervention.	Yes   No
Consumer is at risk of out-of-home placement.	Yes   No
Consumer is in out-of-home placement and reunification is imminent.	Yes   No
Currently, Consumer is enrolled in another Medicaid-related program including Individual Counseling, Family Counseling/Training, Crisis Intervention Services, Community Support Team, and/or Residential Services.	Yes   No
Consumer has a current psychological evaluation (2 years or less)? If so, please fax to: 404-501-0033	Yes   No
Does consumer have a CCFA Assessment (DFCS only)? If so, please fax to: 404-501-0033	Yes   No

Summarize reason(s) for admission, current diagnosis and treatment, and past history of mental health/substance abuse treatment.