Referrer Contact Information First Name:    Last Name:    Email: Phone Number:    Work Number:    Referral Type: -Select Referral- DFACS DJJ School Parent/Legal Guardian Family Member Community Center Mental Health Facility Substance Abuse Facility Walk-In Telephone Other   Agency:    Address1:    Address2: City:    State: -Select State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming    Zip Code: Youth Information First Name:    Middle Name:    Last Name: Date of Birth:        Gender: -Select a Gender- Male Female    Race: -Select a Race- Mixed Race African American Caucasian Indigenous Australian Native American North East Asian Pacific South East Asian Other SSN:        Insurance: -Insurance Type- Georgia Medicaid Peach State/Cenpatico Medicaid No Insurance    Medicaid #:    Expiration Date:       Name that appears on Medicaid Card:   Reason referral was made (i.e. identify the issue/problem)? Parent/Legal Guardian First Name:    Last Name:    Email: Phone Number:    Work Number:     Address1:    Address2: City:    State: -Select State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming    Zip Code: Is Parent/Legal Guardian aware of referral? -Select- Yes No Has Psychological been completed? -Select- Yes No If yes, please fax or email form. Location initial assessment can be completed? -Select- Home Office Foster home/Group home Detention Center Other