LEO Clinic Behavioral Health Referral
Submit a community or school-based behavioral health referral for individuals at schools served by LEO Clinic.
Type of Referral
*
Community-Based Referral
School-Based Referral
Person Being Referred - Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Medications Currently Being Taken
Referral Behaviors
Please Select
Anxiety
Depression
Aggression
Attention/Focus Concerns
Defiance or Disruptive Behavior
Mood Swings
Self-Harm Concerns
Trauma-Related Concerns
Social Withdrawal
Substance Use Concerns
Other
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email Address
example@example.com
Referring Party - Full Name
*
First Name
Last Name
Referring Party Role/Relationship
*
Referring Party Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Party Contact Email
example@example.com
If this is a school-based referral, select the school
Please Select
Lincoln Elementary
Oakwood Middle School
Central High School
Other
Reason for Referral
*
Additional Notes or Relevant Information
Consent to Share Information
*
Yes, I have consent to share this information.
No, I do not have consent.
Current Diagnosis
Other Important Information
Open-ended notes/details section
Submit Referral
Should be Empty: