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:*

No InsuranceState / Husky InsuranceCommercial Insurance
Insurance Company:
Policy Number:
Reason for Referral (check all that apply):*

Academic PerformanceClassroom BehaviorBehavior (outside of school)Trauma during the student’s lifetime that has a current impactDepressionAnxietyPeer/Social IssuesGrief/LossFamily IssuesJuvenile justice/police involvementAlcohol and/or other substance useOther Health/Wellness Issues
Additional Comments about Student Behavior or Symptoms:
Referral Source
Your Name:*

First NameLast Name
Email Address:*
example@example.com
Phone Number:*
Referral Source Relationship to the Student:*
Have you informed the Parent/Legal Guardian that Bridges will be calling the family about the referral?*

YesNo
If you responded “No” to the above, do you give permission for Bridges to contact the Parent/Legal Guardian about the referral?*

YesNo
Parent / Legal Guardian's Name:*

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

Student Referral Form

Referral Source