School Based Health Center Referral

USE FOR SCHOOL-BASED HEALTH SERVICES ONLY

Do not use for child guidance clinic (CGC) or other outpatient self-referrals.

Date of Referral*

Student Name*

First Last

Student Date of Birth*

Parent/Guardian Name*

First Last

Primary Phone Number*

Secondary Phone Number

Student's Home Address

Street Address Address Line 2 City State ZIP Code

Referral Source*

SBHC Nurse Practitioner
School Admin/Staff
Parent/Self
Other

School Admin/Staff*

Other*

Type of insurance:*

School Name*

Grade

Is parent aware of referral?*

Yes
No

please specify*

Primary language spoken at home?

Current DCF involvement?

Yes
No
Unknown

Special education student?

Yes
No
Unknown

Does IEP have counseling included?

Yes
No

504 student?

Yes
No
Unknown

Are there other school services and/or personnel involved?

Yes
No

List other school services and/or personnel involved

Are there other community resources involved

Yes
No

Other community resources involved

Is this specifically a referral for Cognitive Behavioral Interventions for Schools (CBITS) or Bounce Back (BB)

Yes
No
Unknown

Have there been prior CFA services including SBHC referrals?

Yes
No
Unknown

Presenting Problems

Describe the social/emotional issues or problem behaviors that concern you most about this child.

Problem list

choose all that apply

Describe other presenting problems not listed

Your request will be reviewed within 2 business days. In the meantime if you experience a mental health emergency, please call 211, 911 or take the child to the nearest emergency department.

Please click SUBMIT when done

Forms – SBHC Referral

School Based Health Center Referral

USE FOR SCHOOL-BASED HEALTH SERVICES ONLY

Do not use for child guidance clinic (CGC) or other outpatient self-referrals.

Please click SUBMIT when done