Support Is Available Home About us Services Careers Contact us Faqs Blog Home About us Services Careers Contact us Faqs Blog We’d Love to Hear From You For more information about our services or to schedule an appointment, you may send a message using the contact form or by: Phone: (404) 973-0069(877) 795-1561 E-mail: info@theallianceofhope.com Visiting In Person: 2785 Lawrenceville Hwy. Suite 109/112Decatur, GA 30033 CONTACT FORM Name *Email *PhoneMessage0 / 180Submit We Are Accepting New Referrals Please complete and submit the referral form below to request services. A staff member will reply within 48 hours. First Name *Last Name *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Phone *Email AddressGenderMaleFemaleNon-Binary (X)Please enter identified genderDate of Birth *Is consumer currently receiving services from another provider?YesNoHas consumer recently been discharged from a hospital or crisis center?Please select oneYesNoType of Insurance *MedicaidMedicareAetnaAlliantAmbetterAmerigroupAnthem Blue Cross and Blue ShieldBlue Cross Blue ShieldCareSourceCignaCloverHumanaKaiser PermanenteMolinaOscarUnited HealthcareWellCareNoneMember/ Policy # *0 / 16Marital StatusSingleMarriedSeparatedDivorcedWidowedRace/ EthnicityPlease select oneWhite/ European AmericanBlack/ African AmericanAsian/ Asian AmericanHispanic/ Latin XPacific IslanderUnknownIf consumer has actively served in the military, please select which branchPlease select oneArmyAir ForceMarinesNavyCoast GuardReserves (Any Branch)Is consumer currently employed?Please select oneYesNoIs consumer currently in school?Please select oneYesNoWill consumer require transportation?Please select oneYesNoIs consumer currently taking prescribed medication?Please select oneYesNoWill consumer require special accommodations?Please select oneYesNoName and title of person referring consumerAgency/ organization of person referring consumerEmail AddressPhoneService(s) Requested:Peer Support: Wellness, Whole Health Management, Recovery, Behavioral Structure, Crisis Intervention (Adults only, 2-5 days/ wk.)CORE- Non-Intensive Outpatient Services (NIOP): Individual, Family, and Skills 1-3 visits per weekIFI (Intensive Family Intervention) (3-5 times per week)Psychiatric Evaluation and Treatment/ Medication Management (must be in conjunction with NIOP or Peer Support)Additional Comments:Submit ReferralSave as Draft