Make a Referral

Mental Health Referral Form
CORE Services
Office/Home Phone Number
Client Date of Birth
(If Applicable)
List All Mental Health Diagnosis
List All Medications
***Please Note*** Uninsured families must apply for PeachCare before services can be provided. For more info please visit PeachCare at
Please check all that apply.
List ALL Behaviors In The Past 3-6 Months!
Please explain the client's present challenges/problems.
If yes, to legal involvement, when? Please explain open/pending court case.
*** If child is in the custody of DFCS, please complete consent form.
Required Electronic Signature

***Please upload psychological and psychiatric evaluations:

Psychological/Psychiatric Evaluation Upload files