La Clinica de Familia School Based Health Center Referral Form
We would like to ensure that students have access to medical and mental health services when they need it. This referral form is a way for students, who are interested in services, to contact us directly. Teachers you can also refer students who you think could benefit from the services offered by the school based health center. Types of services typically offered at the school based health center (SBHC) but not limited to: *Acute illnesses such as flu, and chronic conditions such as asthma and diabetes. *Feelings of depression, anxiety, or just need to talk *Birth control *Annual physical or sports physicals *Acne *Have questions about birth control, STIs, or a reproductive health service (can be confidential under State of NM Minor Services) *Substance abuse counseling *Seeking support or interested in joining support groups such as LGBTQ+ or acculturation *Have general medical questions We are scheduling in person appointments and also offer telehealth appointments. We are here to offer a safe and nonjudgmental environment-we are here for YOU! Hours: Mon - Fri 8:00 am - 4:30 pm Phone: 575-343-0601 **IF THIS IS A MEDICAL EMERGENCY PLEASE CALL 911** **IF YOU ARE IN CRISIS PLEASE CALL 1-844-622-7099**
Full Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Parent/ Guardian's Phone Number
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Please enter a valid phone number.
Student's Phone Number
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Please enter a valid phone number.
Email Address Note: Please use a personal email (ex: @gmail.com, @icloud.com, @yahoo.com) instead of school email
example@example.com
Reason for appointment (Check all that apply) Reminder: We do offer confidential services for Minors as addressed in the New Mexico Statutory Authority; this includes counseling and reproduction health services. Services provided by the school based health center are at No Charge to students.
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Counseling
Medical Visit
Annual Physical
Sports Physical
Sick Visit
Support Group
Other
What school does the student attend?
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Santa Teresa High School
Gadsden High School
Chaparral High School
Desert Pride Academy
Rio Grande Preparatory
Centennial High School
Lynn Middle School
Picacho Middle School
Other
Who is referring student?
*
Self
Teacher/Staff
Parent
Person referring student *Note: If you wish to remain anonymous please indicate here.*
Notes/Summary
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