📁 Referring Party Information
Referring Agency / Person *
Title / Position
Referring Party Phone *
Referring Party Email
Referral Source Type *
— Select —
Court / Judge
Attorney / Legal Counsel
Community Agency
Nonprofit Organization
Self-Referral
Family Member
Other
Date of Referral
👤 Client / Individual Information
Client First Name *
Client Last Name *
Date of Birth *
Gender
— Select —
Male
Female
Non-binary
Prefer not to say
Client Phone
Client Email
Client Address
📋 Services Requested
Urgency Level
— Select —
Routine (within 2 weeks)
Urgent (within 3–5 days)
Crisis (immediate attention required)
Court deadline – specify below
Court Date (if applicable)
Reason for Referral / Presenting Concerns *
Relevant History (Mental Health, Substance Use, Prior Treatment)
Safety Concerns or Special Accommodations
💳 Payment / Insurance
Payment / Insurance Type
— Select —
Direct Pay
PeachState (Medicaid Managed Care)
Amerigroup (Medicaid Managed Care)
CareSource (Medicaid Managed Care)
WellCare of Georgia (Medicaid Managed Care)
Commercial Insurance — specify below
Unknown / Need Assistance
Insurance Plan Name (if applicable)
✍ Authorization & Consent
Confidentiality & Authorization Statement
By submitting this referral, the referring party certifies that: (1) the information provided is accurate and complete to the best of their knowledge; (2) proper authorization or consent from the individual has been obtained where required by law; (3) this referral is being made in good faith for the purpose of obtaining lawful clinical services; and (4) the referring party understands that information shared with Attract Success, LLC is protected under HIPAA, 42 C.F.R. Part 2 (where applicable), and O.C.G.A. § 37-3-166 and may only be disclosed with written consent or as otherwise permitted by applicable law.
Notice: Submission of this form does not guarantee service enrollment. All referrals are reviewed promptly and treated as a priority. A staff member will contact the referring party within 1–2 business days to confirm next steps, availability, and any required documentation. Crisis referrals receive immediate attention.
✉ Submit Referral Online
🖨 Print as PDF
✅ Your referral has been received. A staff member from Attract Success, LLC will contact you within 1–2 business days to discuss next steps. For urgent matters, please call us directly.