STAR School Based Counseling Referral

START School Based Counseling Referral
In order to make a program referral, please complete all sections below:
Your Name*

First NameLast Name
Your Role/Title*
Email*
example@example.com
Your Phone #*
Today's Date

MonthDayYear
Youth's Name*

First NameLast Name
Identified Gender*

MaleFemaleTransgenderGender FluidDo not wish to disclose
Birth Date*

MonthDayYear
Diagnosis:
Medication:
School:*
Status of the youth's 504 or IEP plan *
School Phone #
PARENT/GUARDIAN CONTACT INFORMATION
Caregiver Name*

First NameLast Name
Primary Language
Phone #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide a brief description of the youth’s situation and needs:*
Please list any safety concerns we need to be aware of as we provide services:*
What other services is the youth currently receiving?*

Community Based TherapyCommunity Based TreatmentCase managementMedication ManagementNo other services are involvedOther
If the youth is currently receiving other services, what agency/agencies are they working with?
Example: BHP, FIS, Village, etc.?
PLEASE CALL US AT (877) NYAP-CAN IF YOU HAVE ANY QUESTIONS
Should be Empty:

START School Based Counseling Referral