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* First Last Student Date of Birth* MM slash DD slash YYYY Parent/Guardian Name* First Last Primary Phone Number*Secondary Phone NumberStudent's Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School Name* Grade*Pre-K 3Pre-K 4Kindergarten123456789101112Is parent aware of referral?* Yes No Unknown Primary language spoken at home? Current DCF involvement? Yes No Unknown Special education student? Yes No Does IEP have counseling included? Yes No 504 student? Yes No Are there other school services and/or personnel involved? Yes No List other school services and/or personnel involvedAre there other community resources involved Yes No Other community resources involvedReferral Source* SBHC Nurse Practitioner School Admin/Staff Other Referral Source Name* Have there been prior CFA services including SBHC referrals? Yes No Unknown Presenting ProblemsDescribe the social/emotional issues or problem behaviors that concern you most about this child.What is the Student's in school schedule? Monday Tuesday Wednesday Thursday Friday Problem listchoose all that apply Aggressive/assaultive behavior Anxiety related symptoms Community violence Cruelty to animals History of cruelty to animals Destructive to property Distractable Disruption from home Eating disorder Encopresis/Enuresis Family conflict Fire setting Grief/loss High risk behaviors Homicidal History of homicidal Hyperactive Learning problems Legal involvement (see title XII) Low self-esteem Manic Neglect Oppositional behaviors Peer relationship problems Physical abuse Runs away Self-injurious History of self-injurious Sexual abuse Sexual identity Sexual misconduct Sexual reactivity Sleep disturbance Stealing Substance abuse Suicidality History of suicidality Symptoms of depression Symptoms of psychosis School problems School avoidance/truancy Tantrums Trauma/adverse childhood event Other (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? Yes No Describe other presenting problems not listedYour 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
