Walton Empowers Program Referral Form 

  • Community Partner Program Referral

  • Referral Form Instructions

    This referral form is to be completed by a community partner or agency staff member to refer an individual to Walton Empowers programs.

    Please complete the following steps:

    1. Select the Walton Empowers program you are referring the individual to. 
    2. Select your organization/agency from the dropdown list.
    3. Provide your name and contact information.
    4. Based on your selections, you will be guided to program-specific questions on the next pages.

    Please note: the fields on the first page requesting a name, title, phone number, and email address are for the referring staff member, not the individual being referred.

    Please ensure all required fields are completed as accurately as possible. The information provided helps our team better understand the needs of the individual and coordinate appropriate services and supports.

    Submitting this referral does not guarantee program enrollment. A Walton Empowers staff member will review the referral and follow up within 72 business hours.

    For questions, please call 770-266-6788 to speak with a staff member.

  • Which Walton Empowers Program are you referring the individual to?*
  • What organization or agency are you referring from?*
  • Format: (000) 000-0000.

  • Empowering Families

    Provides peer support and connection to resources to individuals and families involved with the Department of Family & Children Services who may have current or a history of substance misuse
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • May Walton Empowers leave a voicemail at this number?*
  • May Walton Empowers send text messages to this number?*
  • What kind of support is this individual seeking? (Please select all that apply)*

  • Bridge to Community

    Provides peer support and connection to resources to individuals and families involved with the Walton County Criminal Justice System who may have current or a history of substance misuse.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • May Walton Empowers leave a voicemail at this number?*
  • May Walton Empowers send text messages to this number?*
  • What is the individuals current status? (Please select the option that best describes the individual being referred)*
  • If the individual is currently incarcerated and awaiting court or scheduled for release, what is the anticipated court/release date?*
     - -
  • What type of support is the individual seeking through Bridge to Community? (Please select all that apply)*

  • Community Connections

    Provides peer support and connection to resources to individuals and families throughout Walton County's Healthcare & Community Settings who may have current or a history of substance misuse.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • May Walton Empowers leave a voicemail at this number?*
  • May Walton Empowers send text messages to this number?*
  • What type of support is the individual seeking through Community Connections? (Please select all that apply)*
  • Does this individual consent to being contacted by Walton Empowers Staff?*
  • Clear

  • We appreciate your partnership and support. Please ensure all information provided is accurate before submitting this form. Our team will follow up on referrals within 72 business hours. Thank you for submitting a referral to Walton Empowers!

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