Apply for Services

Referral Form

For more information about any of the programs and services offered by The Arc Southwest Georgia contact our office at (229) 888-6852 or – email mmccarty@thearcswga.org. If you would like to sign up for our services, download the fill and print version or complete the form below.

Download A Fill & Print Version

Contact Information
Date
MM
DD
YYYY
Name of Individual to be Served
Phone Number
Mailing Address
Street Address City State ZIP Code United States
Person/Agency Making Referral
Relationship
Phone Number
Individuals Information
Date of Birth
MM
DD
YYYY
Medicaid #
Social Security Number
Medicaid #
Medicaid Waiver?
- Yes
- No
Are you applying for a waiver?
- Yes
- No
Diagnosis (list all known)
Assessments/Evaluations?
- Yes
- No
If yes, please attach copies.
Assessments/Evaluations
Drop files here or
Income Source(s)
Reason for Referral
Family Aware of Referral?
- Yes
- No
Contact
Relationship
Phone Number*
Email
Other Pertinent Information

What We Believe

We believe all individuals, regardless of disabilities or exceptional needs, have strengths, abilities, and inherent value and should experience the same opportunities, rights and freedoms as inclusive members of the community.