Request Services

- Access Services

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)
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- Date of Referral: REQUIRED Please fill out this field. Please enter a date.
- Person Making Referral REQUIRED Please fill out this field. Please enter valid data.
- Referring Physician/School/Agency REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Client Last Name REQUIRED Please fill out this field. Please enter valid data.
- Client First Name REQUIRED Please fill out this field. Please enter valid data.
- Client Middle Initial REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- SS# Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Parish or County REQUIRED Please fill out this field. Please enter valid data.
- Client Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Alternate Phone Number (Work/Cell) REQUIRED Please fill out this field. Please enter valid data.
- Insurance - Medicaid #: Please enter valid data.
- Other Insurance -(Name of Company): Please enter valid data.
- Parent/Legal Guardian/Spouse/Next of Kin: NAME REQUIRED Please fill out this field. Please enter valid data.
- Relationship to Client: REQUIRED Please fill out this field. Please enter valid data.
- Phone Number: REQUIRED Please fill out this field. Please enter valid data.
- Alternate Number: Please enter valid data.
- Presenting Concerns/Behaviors REQUIRED Please fill out this field.
- Does the individual (or guardian) know they are being referred to our agency? Yes or No. Please enter valid data.
- 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
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