Loft Referral Form

Date of Referral

Date

Student Name

First NameLast Name

Student's DOB

Date

Student's Grade

Student's Gender

Student's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Name

First NameLast Name

Parent/Guardian Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Referral Source Name

Referral Source Relation to Student

Referral Source Contact

(Phone number or email address)

Guidance Counselor Name

Does the student have a 504 plan/IEP?

Case Manager

Is the student and/or parent/guardian aware of this referral?

Is the student currently or have they ever received any mental health and/or psychiatric services?

Please briefly describe the reason for referral and any relevant history

Person Completing Referral Form

Person Completing Form Contact

(Phone number or email address)

For more info, please contact LOFT Clinician @ sbtheloft@familyconnectionsnj.org or 973-762-5600 ext 1187