By submitting this form, you are representing that the referring clinician has obtained the appropriate consent of the below named patient to share their information with GBHP and to have GBHP contact the patient to evaluate clinical treatment options. You can also download this form and fax it to (407) 878-6663

  • Patient Information

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  • GBHP intake staff will try to honor a patient request; however, requests may not always be feasible due to availability, location, etc.
  • Referral Information

  • Appointment Requests

    Please check all that apply
  • For additional questions, please call the Georgia Behavioral Health Professionals at 678-820-7868. Thank you for referring.