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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 a minor? *

Is the student an international student? *

Student's phone number (if applicable):

OK to leave a message?

Student's email address (if applicable):

Gender: *

Student's address: *

Address Line 1

Address Line 2

City

State

Zip Code

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: *

Health Insurance Plan Name:

Are you covered by a Medicare or Medicaid plan?

Subscriber's Name: