School based clinical referral -

Information About You (Referral Agent)

Referring Agent's Name:

First

Last

Referring Agents Email:

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?

Yes
No

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

OK to leave a message?

Yes
No

Gender:

Student's address:

Address Line 1

Address Line 2

City

State

Zip Code

Is the student 14 years old or older?

Yes
No

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?

Yes
No

Email for parent or guardian:

The Challenges

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

Are you aware of the referral talking about ending his/her life?

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

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

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.

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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.