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.Date of Referral* MM slash DD slash YYYY 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Referral Source* SBHC Nurse Practitioner School Admin/Staff Parent/Self Other School Admin/Staff* Other* Type of insurance:* School Name* Bennie Dover Jackson Middle School (New London) Catherine Kolnaski STEAM Magnet School (Groton) C.B. Jennings International Elementary Magnet School (New London) Dr. Charles G. Barnum School (Groton) Ella T. Grasso Technical School (Groton) Fitch High School (Groton) The Friendship School (Waterford) Gales Ferry School/Juliet W. Long School (Gales Ferry/Ledyard) Gallup Hill School (Ledyard) Groton Middle School (Groton) Ledyard High School (Ledyard) Ledyard Middle School (Gales Ferry/Ledyard) Mystic River Magnet School (Groton) Nathan Hale Arts Magnet School (New London) New London High School (New London) Northeast Academy (Groton) Regional Multicultural Magnet School (New London) Stonington High School (Pawcatuck) Stonington Middle School (Stonington) Thames River Magnet School (Groton) West Vine Elementary School (Pawcatuck) Winthrop STEM Magnet Elementary School (New London) GradeIs parent aware of referral?* Yes No please specify* Primary language spoken at home? Current DCF involvement? Yes No Unknown Special education student? Yes No Unknown Does IEP have counseling included? Yes No 504 student? Yes No Unknown 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 involvedIs this specifically a referral for Cognitive Behavioral Interventions for Schools (CBITS) or Bounce Back (BB) Yes No Unknown 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.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 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
