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Child and Family Agency

Child and Family Agency

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Forms – SBHC Referral


SBHC Referral (rev 20220315)

SBHC Referral 2022-03-15

"*" indicates required fields

School Based Health Center Referral

USE FOR SCHOOL-BASED HEALTH SERVICES ONLY

Do not use for child guidance clinic (CGC) or other outpatient self-referrals.

Student Name*
MM slash DD slash YYYY
Parent/Guardian Name*
Student's Home Address
Is parent aware of referral?*
Current DCF involvement?
Special education student?
Does IEP have counseling included?
504 student?
Are there other school services and/or personnel involved?
Are there other community resources involved
Referral Source*

Have there been prior CFA services including SBHC referrals?
Describe the social/emotional issues or problem behaviors that concern you most about this child.
What is the Student's in school schedule?
Problem list
choose all that apply
(New London High School Families only): Would client participate in telehealth sessions during the school day with an alternative Child and Family Agency provider, when School Based services are not immediately available?
Your request will be reviewed within 2 business days. In the meantime if you experience a mental health emergency, please call 211, 911 or take the child to the nearest emergency department.

Please click SUBMIT when done

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