Resolution Behavioral Health, LLC

Resolving challenges one step at a time

Client Referral

Date*

Referral Phone #*

Referral Fax #

Client Name(s):

DOB

Client Address

Emergency Contact Name and Number

Insurance Provider:

Medicaid Number:

Physician Name and Number:

SERVICES REQUESTED:

CounselingAnger ManagementSubstance Abuse CounselingParentingFamily/Community SupportDrug Assessment

REASON FOR REFERRAL/TREATMENT:

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3575 Macon Road Suite 8 Columbus, GA 31907 Phone: (706)-641-2414

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