SCHOOL-BASED REFERRAL FORM

SCHOOL-BASED REFERRAL FORM
STAFF INFORMATION (REFERRING PARTY)
Today's Date

MonthDayYear
Date
Staff Name

First NameLast Name
Phone Number with Extension
Fax Number
Email Address
example@example.com
School Name
STUDENT INFORMATION
Student Name*

First NameLast Name
Gender

MaleFemaleOther
Grade
Date of Birth*

MonthDayYear
Date
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Child
Do you need an additional parent/guardian?

YesNo
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Child
Does the student presently receive any of the following services (please check where appropriate):

School CounselingSchool NurseSchool Social WorkerIndividual Education Plan504 PlanOutside TherapyCounty Case Management/Services
REASON FOR REFERRAL
Please briefly explain include issues/problems affecting student on a daily basis and why school-based therapy is being recommended:
Impact on grades, behavior, attendance?
Is there any other information that may be helpful to our staff?
Parent/Guardian: Click here to complete our Release of Information Form if necessary.
Therapist you’re scheduled with*

First NameLast Name
Should be Empty: