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 #
Format: (000) 000-0000.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Youth's Name

First NameLast Name
Identified Gender
Birth Date

MonthDayYear
Diagnosis:
Medication:
Who Holds Custody of Person Served?
School:
Status of the youth's 504 or IEP plan
School Phone #
Format: (000) 000-0000.
INSURANCE/MEDICAID INFORMATION
Insurance/Medicaid Name
Insurance/Medicaid Number
#XX00000000
PARENT/GUARDIAN CONTACT INFORMATION
Caregiver Name

First NameLast Name
Primary Language
Phone #
Format: (000) 000-0000.
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?

Other
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
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START School Based Counseling Referral