Home About Our Team Access Services Online Payments Careers Contact Us Request Services ACCESS SERVICES Our Treatment Approach Our Services Request Services Service Request PDF Individual Served Packet Insurance & Fee Policy Compliance & Regulatory HIPAA Community Resources PLEASE COMPLETE THE FORM BELOW AND WE'LL RESPOND TO YOUR INQUIRY WITHIN 24 HOURS. If you prefer, please click on the SERVICE REQUEST link at left and open the PDF form. Then, save the form to your desktop, complete it and email it to your preferred Access office Atlanta (click here to email us) Savannah (click here to email us) Date of Referral: REQUIRED Person Making Referral REQUIRED Referring Physician/School/Agency REQUIRED Email REQUIRED Client Last Name REQUIRED Client First Name REQUIRED Client Middle Initial REQUIRED Gender REQUIRED Date of Birth REQUIRED SS# City REQUIRED State AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY Zip Parish or County REQUIRED Client Phone Number REQUIRED Alternate Phone Number (Work/Cell) REQUIRED Insurance - Medicaid #: Other Insurance -(Name of Company): Parent/Legal Guardian/Spouse/Next of Kin: NAME REQUIRED Relationship to Client: REQUIRED Phone Number: REQUIRED Alternate Number: Presenting Concerns/Behaviors REQUIRED Does the individual (or guardian) know they are being referred to our agency? Yes or No. How did you hear about Access MHA? Additional Information you wish to provide regarding reasons for your visit A valid driver's license or state ID, insurance card, and (for children) birth certificate or Court decree of legal custody must be provided at the time of the first appointment Submit This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Home About Our History Mission & Vision Values Access Ethics Statement Access Locations News / Events Take Our Survey Access Brochures Our Team Access Services Our Treatment Approach Our Services Request Services Insurance & Fee Policy Compliance & Regulatory HIPAA Community Resources Online Payments Careers Contact Us Login powered by Sheenomo™