School-Based Behavioral Health Referral

Date: Click or tap to enter a date.

Student Name: Click or tap here to enter text.
Current School: Click or tap here to enter text.	Grade: Choose an item.
Home Address: Click or tap here to enter text.	Zip Code: Click or tap here to enter text.
Phone Number: Click or tap here to enter text.
Parent/Guardian Name: Click or tap here to enter text. Was Parent/Guardian notified of referral? Choose an item.
Insurance Type: Choose an item.

Name & Title of Person Initiating Referral: Click or tap here to enter text.
Phone: Click or tap here to enter text. Email: Click or tap here to enter text.

Check all the concerns you have about your child:

☐ Aggression (arguing, forcing submission, bullying, fighting, stealing)

☐ Disruptive Behavior (defiance, noncompliance (teacher/school), not following rules, out of designated area)

☐ Hyperactive Behavior (tantrums, disturbing others, excess energy)

☐ Withdrawn Behavior (prefer being alone, non-participation, unresponsive to social initiations, not talking with others)

☐ Depressed Mood (overall sadness, low/restricted activity levels, crying, poor appetite)

☐ Unassertiveness (shy, being timid, not standing up for one’s self)

☐ Anxiety (acting in a fearful manner, appears overly stressed, inability to cope with daily functioning)

☐ Other: Click or tap here to enter text.

Please describe the reason for completing this referral: Click or tap here to enter text.