Referral Form – Building Blocks Counseling

(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 Information
Name 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 documentation
File
Drop files here or

Accepted file types: doc, docx, txt, pdf, Max. file size: 5 MB, Max. files: 5.
Comments
This field is for validation purposes and should be left unchanged.

School Information