Substance Abuse Treatment Program
Referral Form
Please email the completed form to:
TREEhousereferral@chris180.org
Or call 404.613.1658
Location (circle best option)
North Fulton Service Center Fulton County Juvenile Court
7741 Roswell Road, Suite 101, Atlanta, 30350 395 Pryor Street SW, Atlanta, GA 30312
Referral Source
Contact Name: Relationship to Consumer:
Organization (DFCS, School Name, Physician’s Office):
Telephone #: Email:
Consumers Name:
DOB: Gender: Race/Ethnicity:
Address:
Telephone #: Email:
School & Grade: ______________________________________________________________________________
Parent/Guardian Name(s):
Telephone #: Email:
Reason for Referral:
Involvement with other agencies: _____________
Current Medical Problems:
INTERNAL USE ONLY:
Assessment scheduled with:
Date/Time of assessment:
Scheduled by: Reminder Call: Date/Time:
