Behavioral Health Referral Form

When a Neighbor in Need would like a referral to behavioral health care, substance abuse recovery, or crisis services anywhere in the state, Vincentians may complete this form. SVdP Georgia’s partner, Claratel, will contact the Neighbor to connect them to an appropriate provider in their area. For those who can be served by Claratel, they will accept Medicaid patients as well as those without insurance. For those who cannot be served by Claratel, the Neighbor will be offered contact information for other area providers. Cases referred by Vincentians will be prioritized.

Vincentians — You must get your neighbor’s permission before submitting this form.

"*" indicates required fields

Neighbor's Information

Please make sure you have your neighbor's permission before submitting this form.

Neighbor's Name*

First Last

Neighbor's Date of Birth*

Neighbor's Phone*

Neighbor's Email*

Description of Neighbor's Condition:*

Do they have a history of mental health issues?*

Yes

Unknown

If yes, please describe:*

Caseworker Information

Caseworker's Name*

First Last

Caseworker's Phone*

Caseworker's Email*

Conference*