Please select the appropriate link below to begin the referral process:

1) Select one of the following links below to download an offline version of the Pre-Referral Questionnaire:

PowerPoint (.pps)
Microsoft Word (.docx)


2) Click the link below to download the most current copy of the referral form indicated by the Pre-Referral Questionnaire. Please DO NOT use a form with dates prior to those listed below:

CME Intensive Customized Care Coordination: 3/16/17
DFCS/Georgia Families 360 (AG360): 7/13/17

3) Email the completed form to the CME of your choice (select only ONE (1) CME), indicated at the bottom of the form.

If you already have a copy of this form, please verify the form matches the dates above before use.

        Please Email if you need assistance in completing the referral

About the Pre-Referral Questionnaire:

The questionnaire links above help us determine how to best assist you in making a referral and significantly increase the chances of a successful enrollment.

For youth who qualify, you will be directed to a link to begin the referral process. However, if a youth does not qualify, you will be provided with additional information about resources or additional information needed. You will also have the option to leave your information so one of our System of Care Coordinators (SOCC) can contact you.