School-Based Counseling Partnership Program Referral Form

School-Based Counseling

Partnership Program

Referral Form

Information About You (Referral Agent)

Referring Agent's Name: *

First

Last

Referring Agents Email: *

Confirm Email

Name of School: *

Name of the student you are referring: *

First

Last

Students date of birth: *

Is the student an international student? *

If the student is 18+, please include their phone number

OK to leave a message?

Gender: *

Student's address: *

Address Line 1

Address Line 2

City

State

Zip Code

Is the student 14 years old or older? *

Students age 14 and older in are required to sign the informed consent.

Student's email address *

Student's email address

We are required to obtain informed consent from the student’s parent or legal guardian. If you have guardianship papers on file, please submit them to us at the end of this form. If we do not have the correct name and contact information for the parent or guardian, it may cause a delay in service.

Name of parent or guardian: *

First

Last

Phone of parent or guardian: *

Ok to leave a message? *

Email for parent or guardian: *

The Challenges

Please give a brief summary of the reason for the referral: *

Has the referral talked about ending his/her life? *

If the student has discussed ending his/her life please consider the safety of the student and whether immediate assistance through a local hospital or emergency facility is needed.

Are you aware of any current or past mental health treatment for this referral? *

Please describe: *

Has the parent or guardian been contacted regarding the need for counseling services? *

Tell us how the parent or guardian would like to pay for services

Referral agents from schools may not have this information available. Christian Family Solutions staff will contact the parent or guardian to obtain their payment information. For students with commercial insurance or an inability to pay, Christian Family Solutions will provide an initial set of counseling sessions at no cost through our Teen Counseling Endowment Funds.

Choose a payment method: *

Are you covered by a Medicare or Medicaid plan?

Subscriber's Name:

Subscriber's date of birth:

Subscriber's or Member ID Number:

Group Number:

Employer Name:

Verification / Customer Service Phone Number:

File Attachments:

Click or drag files to this area to upload. You can upload up to 3 files.

If you’d like to attach a file for this referral, please attach the file here. Collateral material may include a health consent form for an international student, legal guardian paperwork, health insurance information, or other notes or forms you’d like the counselor or our intake staff to have. Attachment must be in .pdf format.

To protect privacy, all of the information you have entered is encrypted and stored securely. After you submit this information, a Christian Family Solutions representative will contact the student’s parent or guardian to obtain informed consent and then an appointment will be scheduled.

Name *

First

Last

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School-Based Counseling

Partnership Program

Referral Form

The Challenges

If the student has discussed ending his/her life please consider the safety of the student and whether immediate assistance through a local hospital or emergency facility is needed.

Tell us how the parent or guardian would like to pay for services