Consumer Referral Form

Thank you for considering Family360, Inc. as your mental and behavioral health provider. Please complete our Referral Form with as much available information to expedite processing time. Should you require assistance, please contact our offices at (678) 571-1197. Once complete, feel free to email completed form to our secure email at or fax to (678) 806-4876. Be sure to visit us on the web at for more information.

Client’s Information

Other Involvement