Make a Referral

Caseworkers, agencies, schools, parents, and guardians can use this secure form to refer a child or adult to Progressive Counseling. Our intake coordinator will review eligibility and contact you about next steps. Response and appointment times depend on availability.

404-209-1209

HIPAA-secure submission

Patient information

Tell us about the person being referred.

First name*

Last name*

Address*

City*

State*

ZIP*

Contact number*

Date of birth*

Race / Ethnicity*

Email*

Gender

Insurance information

Provide whatever coverage details you have available.

Medicaid #

Other insurance carrier

Other insurance member ID

If the patient is a minor

Optional — leave blank for adults.

Name of school

Grade

Who does the child live with?

Parent / Guardian name

Is anyone else in the household receiving services?

Clinical information

Help our intake team triage and assign the right clinician.

Current medications

Reason for referral

Referrer information

Tell us who is making this referral and which county to bill / serve.

Referral source*

Referrer name*

County for referral*

P.O. / Caseworker name

Caseworker phone

Caseworker email

By submitting this form, you confirm you have authorization to share this protected health information with Progressive Counseling for the purpose of treatment, payment, and operations.

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