Legion For Hope - Contact Us
Legion For Hope  - Empowering our Community
Contact Us

Please fill out the form below to request applications or information on programs and services.
Office: (678) 901-9772
Fax:      (770) 727-2943
Online Referral Form
Referral Agency & Name
Referral Source Phone Number
Attention
Consumer First, Last Name
Consumer Phone Number
Date of Birth
Social Security #
Medicaid Number
Gender
Street Address
City
State
County
Mental Health/Substance Abuse Diagnosis
Current Medications
Presenting Symptoms
Presenting Problems in Detail
Services Requested
Treatment Goals or Areas the consumer would like to work on
Current Treatment Provider Name, Address, Phone#