Redo-School-Based-Therapy-Referral

Today's Date

Type of therapy

Family

Individual

Family & Individual

Preferred location

In-Person

Virtual

No preference

Caregiver is aware of referral

Yes

No

Last Name

First Name

Middle Initial

Date of Birth

Age

School Grade

Address

City

Zip Code

Family Size

Language Preference

Gender/Gender Identity

Religion

Race

Ethnicity

Payment Method: Hazelwood School District

Legal Guardian

Two Biological Parents

Two Adoptive Parents

Biological Mother Only

Biological Father Only

One Biological Parent and One Step Parent

Foster Parent(s)

Adoptive Father only

Adoptive Mother only

Aunt

Uncle

Sibling

Cousin

Grandmother

Grandfather

Children’s Division

Other

Legal Guardian Name(s)

Home/Cell #

Email

Preferred Contact Methods (check all that apply)

Home/Cell

Email

Call

Text

Can Leave a Message

Care Provider(s)

Home/Cell #

Email

Preferred Contact Methods (check all that apply)

Home/Cell

Email

Call

Text

Can Leave a Message

School Building

Social Worker/School Counselor

Social Worker/School Counselor Phone Number

Social Worker/School Counselor Email

Referral Source

Phone Number

Relationship to Student

Email

Time(s) and Day(s) student is available for therapy sessions at school

Reason for Referral

Adoption

Aggression/ Anger

Anxiety

Coping with change

Depression

Foster Care

Grief/Loss

School Aggression

School Suspensions

Social Skills

Trauma- Abuse/Neglect/Physical/Emotional

Other

Additional information related to reason for referral

Previous or Current Diagnosis , if any

Current Medications

List your desired goals and outcomes of therapy

Other Pertinent information (I.e. Specify the type of therapy recommended, preferences, and specific requests)

Type characters you see in the image below

Redo School-Based Therapy Referral Form

Student Information

Guardian Information

School Information

Referral Infomation