Program-Referral

Program Referral and Intake Form

For any questions about the Referral Form, please contact our Administrative Assistant at (404) 298-0888.

Services Provided

  • Community Support Individual
  • Parent Skills Training
  • 24 Hour Crisis Intervention
  • Educational Advocacy & Support
  • Mentoring & Tutoring
  • Self-Esteem Guidance
  • Social and Life Skills Training
  • Community Linkage
  • In-Home Counseling
  • Diagnostic Assessment/Evaluation
  • Individual Counseling
  • Family & Group Counseling
  • Nursing Assessments & Services
  • Comprehensive Child and Family Assessments (CCFA)

Referral Forms

Please fill out the form below

    Name of Consumer*

    First Name

    Last Name

    Name of Person Making Referral*

    Referral First Name

    Referral Last Name

    Email Address

    Phone Number

    Address

    City*

    State*

    Zipcode

    Agency Information
    Please use the space below to input the following information:

    Referral Agency
    Agency Contact
    Email
    Phone#
    Medicaid#
    Wraparound Services

    Agency Information

    Has Psychological been completed?*

    If Yes, please send documents via email to info@pccounseling.org, fax 404.298.0222 or efax 678.609.2980

    Summary of Services Needed

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