Behavioral Health Referral Form
Information about Person Completing Referral
Your Name
First Name
Last Name
Your Position/Title
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Information
Referral Name
*
First Name
Last Name
Referral Date of Birth
*
-
Month
-
Day
Year
Referral Email
example@example.com
School Name
*
If applicable
Parent/Guardian Name (if applicable)
*
First Name
Last Name
Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
*
example@example.com
Individual Gender
Male
Female
Other
Individual Primary Language
English
Spanish
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Referral
Is Student's Parent(s) aware of this Referral?
*
Yes
No
Type of Services Needed
*
Brief Individual
Groups
Ongoing Individual
Groups
Stress Less - Stress & Anxiety
Feel it to Heal it - Coping Skills and Emotional Wellness
Own Your Time - Time Management
None
Reason for Referral
*
Current Medications
Select all applicable challenges below for the Individual referred (check all that apply)
*
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
PRTF/Hospital Discharge
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
Other
Submit
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