Youth and Family Tree Referral

Youth and Family Tree is a program that supports young people to accomplish their goals. The program works with individuals ages 14 to 25 who have experienced issues with using substances and/or their mental health.

Admission Criteria:
☐ The client is 14-25 years old.
☐ The client could benefit from support with their mental health.
☐ The client could benefit from support for their use of substances.
☐ The client resides in Fulton or Dekalb county.

Last name, First name

Initials of Referred Person

* must provide value

Best contact number for client

Date completed (MM/DD/YY)

Date of birth (MM/DD/YY)

The client is 14-25 years old

Yes

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Would the client benefit from support with their use of substances?

Yes

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Would the client benefit from support with their mental health?

Yes

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Which site of Youth and Family Tree are you referring to?

* must provide value

What county does the client live in?

Please list other county:

Referral location

Please describe:

Grady Medical Record Number (if applicable)

Referral location

Please describe:

Grady referral location

Please describe:

Provide a brief narrative summary. Please include information about use of substances, mental health symptoms, current diagnostic impression, and recent treatment.

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Best family contact regarding the referral

Best family contact number regarding the referral

Person's name completing this form

Best contact number regarding the referral

Best contact email regarding the referral

Additional referral notes

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