IT Provider Sheet
Contact 229-225-4358 to confirm your form submission.
"
*
" indicates required fields
Name
*
First
Middle Initial
Last
Date of Birth
*
MM slash DD slash YYYY
SSN
*
Gender
*
Male
Female
Start Date
*
MM slash DD slash YYYY
Organization
*
Select One
DBHDD Region 4 Field Office
Benchmark Human Services
Professional Case Management Services of America
The Columbus Organization
Other
Site
*
Support Coordination
Other
Program
Select One
IDD - Program
#420 - 803 Boulevard
# 417 - Sasser Store Rd
#412 - 1403 Hunters Chase
#413 - 1517 Wright St
#414 - 211 Hunters Chase
#429 - Lincoln St.
411 - 189 Tallokas Estates
419 - 2701 5th Street SE
425 - 1515 4th Avenue NE
488 - Community Homes Nursing
702- Hilltop Lodge
707 - Robert's Transitional Apts.
AD - IOT & OP
ADA-CM, Med Maintenance & Tx Court Services
Add Dis - Outpatient Svcs
Addictive Diseases Outpatient Services
Administrative Support Svcs
APEX - Central Division
APEX - Eastern Division
APEX - Western Division
APEX Program
ARSC & MAT
Bermuda 147
BH Residential Services
BHCC - 1st Shift
BHCC - 2nd Shift
BHCC - 3rd Shift
BHCC Patient Care
Billing Services
CCM - Add Dis CM
Cloverdale 148
Colquitt MH
Community Case Management
Crisis - Admin
Crisis - Beh Health Assessors
Crisis - Director of Nursing
Crisis Services
Decatur IDD Residential 1 (TM)
Decatur IDD Residential 2 (CD)
Financial Services
Georgia Recovery Project
Human Resources
Information Systems
Medical Staff
Mental Health Residential
MH Respite Apartments
Phoenix Admin
Phoenix Patient Care
PHX - 1st Shift
PHX - 2nd Shift
PHX - 3rd Shift
Purchasing & Maintenance
TASC
Thomas DD Residential
Timberwood 151
A.C.T. Team
Georgia Pines
Management Team
Mitchell MH
Accounting & Property
AD Services
Advocacy
Clinical Services
Intellectual & Developmental Disabilities
Medical Services Nursing Staff
Mental Health Outpatient Services
MH Day Services
Outpatient Admin Support
Ber/Clo/Lake
Colquitt DD Residential
Community Homes Admin
Decatur IDD Residential Administration
Decatur/Seminole MH
DSSC - Nursing
Grady Day Svcs
Lakeview 149
MH Group Homes
Phoenix Counseling
Staff Dev
Thomas IDD Res Admin
Thomas MH
Thomas PSR-Peer
481 - Grady St.
482 - Lois Lane
483 - Spair St.
484 - Pear St.
485 - Oak St.
486 - Crabapple Dr
DSSC - Day Hab
DSSC Annex
Other
County
Thomas
Grady
Colquitt
Mitchell
Decatur
Seminole
Check All that Apply, please.
Immediate (Clinical) Supervisor
2nd Level Manager
Education Completed
*
Select One
High School Diploma\GED
AA
AS
BA
BS
BSW
MA
MS
MSW
PhD
Major
Are you professionally licensed or certified?
No
Yes
If not, are you working towards a license/certification?
If Yes, what type:
License
NPI
DEA Permit
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Name
Phone
Section
Couples Therapy
Relationships
Depression Therapy
Children Therapy
Individual Therapy
Anxiety Disorder
Date
Get a consultation
Georgia Pines
Menu
Home
About
Mission & Vision
Staff Leadership
Board of Directors
Pines of Promise
Public Meetings & Events
FY 2024 Annual Report
Services
Addictive Disease
Mental Health
Developmental Disabilities
Inpatient & Residential Programs
Child & Adolescents
Advocacy
Specialty Services
Resources
Intern IT Sheet
IT Ticket Submission
News
Staff Page
Helpful Links
Human Trafficking Hotline
Contact
Contact
Suggestions and Complaints
Join Our Team
EAP
+1 234 56 78 123
Get your first free online consultation
Bibendum neque egestas congue quisque egestas diam. Laoreet id donec ultrices tincidunt arcu non sodales neque
Name
Phone
Section
Couples Therapy
Relationships
Depression Therapy
Children Therapy
Individual Therapy
Anxiety Disorder
Date
Get a consultation
