Referral

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If you or anyone you know can benefit from any of our services, please complete the referral form below and we will contact you.  You may also print the form, and email or fax it to our office.

Office 404-564-4796

Fax 866-669-0494

Email email@theimaracenter.com

To make a referral to the Imara Center, please complete the form below.

Referral Info:

Consumer Information:
Consumer #1 Insurance Type Insurance# DOB Gender MF
Consumer #2 Insurance Type Insurance# DOB Gender MF
Consumer #3 Insurance Type Insurance# DOB Gender MF
Consumer #4 Insurance Type Insurance# DOB Gender MF
Consumer #5 Insurance Type Insurance# DOB Gender MF
Parent Info :
Name of Parents/Guardians:
Email of Parents/Guardians:
Address: City: Zip Code:
Phone Home: Phone Cell: Phone Work:
Diagnosis:
Hospitalization History:
Medications:
Legal Issues:
Reason Child is being referred:
Truancy Disruptive Behavior Sign of Depression Anger Issues
Academic Issues Multiple Detentions/Suspensions Grief/Loss Substance Abuse
Adult CORE Groups Other
Referral Information:
Referred by: Title:
Contact Email: Phone number:
Referring Agency/Org: School Name:
Referral Source made contact to Parent? Date:
IC Team Only:
Parent contacted: Date: Made contact: Assessor Assigned:
Download Form