(Student) Client's Name* First Last Date of Birth* MM slash DD slash YYYY Parent/Guardian's Name(if under 18) Phone Number*Email Address* Does the student have health insurance?* Yes No Referring Counselor Name* Referring Counselor Email* Referring Counselor Phone*School InformationName of School* Grade* Preferred day/time for in school session* Email to send telehealth session link* Please describe reasons for referral, and attach any related documentationFile Drop files here or Select files Accepted file types: doc, docx, txt, pdf, Max. file size: 5 MB, Max. files: 5. EmailThis field is for validation purposes and should be left unchanged.
