Program Referral and Intake Form

Family Intake Form

Please fill out this form to get started with our Services


    (Place a check next to the Service/s you’re interested in receiving)

    Behavioral Health AssessmentIndividual CounselingFamily & Group CounselingParent Skills TrainingSocial & Life Skills TrainingNursing AssessmentCrisis InterventionPsychological TestingSelf-Esteem BuildingPsychiatric EvaluationMedication ManagementDiagnostic AssessmentCommunity Linkage/ SupportDrugs & Substance AbuseCoping/Skills Management






    MaleFemale














    YesNo


    “If yes, we cannot service them until they’re discharged

    YesNo

    YesNo

    If yes ,








    Contact us to schedule an appointment.

    Contact Us

    3883 Rogers Bridge Road, Suite 202A, Duluth GA. 30097, U.S.A
    View Map & Directions »

    Phone Number: +1 (770) 545 8359
    Fax Number: (229)-515-4233
    info@familywellnesscenterllc.com