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Shelby County
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Home
About Us
Contact
Services Offered
Speaking Engagments
Therapeutic Groups
Group Home Page
R.E.S.T.O.R.E-Healthy Relationships
P.R.O.C.E.S.S- Emotional Regulation Group
REDEEM
All Group Registration Form
Shelby County
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Date of Referral
*
Name of Client
*
DOB
*
Client's address
*
Medicaid Number
BCBS/AllKids Number
Parent/Guardian Name
*
Contact Number
*
School
*
Reason for Referral
*
Primary Care Physcician
*
Person making referral name and number
*
Social worker name and number
*
Email address
*
Select a Choice
*
Birmingham
Montgomery
Submit
Department of Human Resources
Online Referral Form
Printable Referral Form