Student Referral Form (School Based Services)

Student Referral Form

(School Based Services)
Bridges Healthcare School-based Therapy Program provides services to students in their schools. There is no cost to families for the services; insurance is billed, when it is available. Please complete the Referral Form below, if you believe a student can benefit from our services.
Referral Date:

MonthDayYear
Date
Student's Name:

First NameLast Name
Student's Date of Birth:

MonthDayYear
Date
School Attending:
Grade:
Health Insurance Type:
Insurance Company:
Policy Number:
Reason for Referral (check all that apply):
Additional Comments about Student Behavior or Symptoms:
Referral Source
Your Name:

First NameLast Name
Email Address:
example@example.com
Phone Number:
Format: (000) 000-0000.
Referral Source Relationship to the Student:
Have you informed the Parent/Legal Guardian that Bridges will be calling the family about the referral?
If you responded “No” to the above, do you give permission for Bridges to contact the Parent/Legal Guardian about the referral?
Parent / Legal Guardian's Name:

First NameLast Name
Email:
example@example.com
Phone:
Format: (000) 000-0000.
If you have any questions about the referral form please email schoolreferrals@bridgesmilford.org
Should be Empty:

Student Referral Form