School Referral for Behavioral Health Services
Please provide as much information as possible so that we can reach out to the family, parent, or caregiver. Alternatively, you can have the family contact us at 888-666-3089 or through email at appointment@patsconsultants.com
Student's Information
Child/Youth's Name:
*
First Name
Last Name
DOB:
*
-
Month
-
Day
Year
Date
Age:
*
School Name:
*
Reason for Referral: Check all that apply
*
If other, please state reason below:
Name of Parent or Guardian:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Best time to contact family:
Ex: Monday/Wednesday
Ex: Mornings/Afternoons
Is the parent or caregiver aware of the need for referral?
Have you given the parent our contract information?
Is there anything else that you think we should know about this referral?
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School Referral for Behavioral Health Services
Referrer's Information
Date:
-
Month
-
Day
Year
Date
Your Name:
First Name
Last Name
Your Telephone number:
Reason for Referral:
Your Position:
Should be Empty: