Millbury Public Schools Therapy Request Form

Pediatric Behavioral Health

Client Information Form For School-Based Referrals
School Atteding
General Information
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Student Gender*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Name*

First NameLast Name
Parent/Legal Guardian Phone Number*
Format: (000) 000-0000.
Parent/Legal Guardian Email (this one will be used for patient portal)*
Other Legal Guardian Name*

First NameLast Name
Other Legal Guardian Number*
Format: (000) 000-0000.
Insurance

A credit card will be required to be placed on file for all copays/coinsurance and applicable charges will be run on the date of service
MA Brigham WilliamsBlue Cross / Blue ShieldFallon Health / CarelonGIC/WellpointHarvard Pilgrim Health CareHealth Plans, IncUMRUnicareUnited Health CareTuftsSelf Pay
Policy Number*
Subscriber Name*
Subscriber DOB*
Student's Primary Care Doctor *
Millbury School's Referring Counselor*

Please check if the following are of concern for your child.*

Rows	Concerned	Not Concerned
Adjustment to change
ADHD
Anger
Anxiety / Worries / Panic Attacks / Fear
Autism Spectrum Disorder
Body Image Issues / Eating Disorder
Bullying
Chronic Pain / Chronic illness
Chronic Hair Pulling
Cyber Addiction
Grief / Loss
Juvenile Sexual Issues
LGBTQ Issues
Mood Swings / Depression / Sadness
Obsessive / Compulsive Disorder
Perfectionism
Relationship Issues (dating, friendships, family)
Self Esteem Issues
Sleep Disturbances
Parent / Child Relationship Issues
Planning for College
Psychosis
Suicide Attempt / Self Harm
Substance Abuse
Trauma
School Refusal / Significant Absences

Description of Presenting Problem*
Are Both Parents Aware of the School Referral for School based therapy?*
Please describe any concerns either parent may have about this referral*
If you are seeking therapy for a child in grades preK-6 it is required that a parent attend every session with their child to be accepted for school based therapy. *
Date:

MonthDayYear
Should be Empty:

Pediatric Behavioral Health