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Community Referral

Trusted Sources

Know someone who could use a hand? Submit a referral on their behalf and our team will follow up within 24 hours to discuss available support and care options.

Your Information

Your Name*

Relationship to Person

Phone*

Email*

Best Time to Contact

Preferred Contact Method

PhoneEmailText

About the Person You're Referring

Name or Initials (Optional)

County of Residence

State

Age Range

Under 1212-1718-2425-3435-4445-5455-6465+

Current Living Situation

Lives with FamilyIndependent LivingFoster CareGroup HomeTransitional HousingResidential TreatmentHomelessIncarceratedUnknown

What Help Is Needed

Types of Help Needed

Mental Health CounselingSubstance Abuse RecoveryFamily SupportParenting SupportCrisis InterventionFood AssistanceHousing AssistanceChild/Youth SupportVeteran ServicesFaith-Based SupportCase ManagementOther

Brief Description of the Situation

How urgent is this situation?

Immediate (24 Hours)High Priority (72 Hours)Moderate (1 Week)Routine

Ability to Pay & Scholarship

Insurance Status

Private InsuranceMedicaidMedicareSelf PayUninsuredUnknown

Can they afford to pay for services?

Can Pay Full CostCan Pay PartialCannot PayUnknown

Do they need scholarship assistance?

YesNoUnsure

Financial Notes (Optional)

Additional Notes

Anything else we should know?

Fields marked * are required. All information is kept confidential.

Helping People Find Hope and a Path Forward.

"Carry each other's burdens, and in this way you will fulfill the law of Christ." — Galatians 6:2

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Get in Touch

info@trustedsourcesga.org
(470) 239-0015
Serving Georgia