School Referral

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	Request for Behavioral Health (Mental Health or Substance Use) Assessment and/or Linkage with Family Service League, Inc.

Date

School Name

School District

Requestor's Contact Information

First Name

Last Name

Callback Number

Email Address

Secondary Contact Information (i.e. if need to reach different staff member after hours, etc.)

First Name

Last Name

Callback Number

Email Address

Referral Information

Referral Type

Mental Health

Substance Use

Mental Health & Substance Use

Referral Reason

Does the Student have an IEP/504 Plan?

Student's Information

First Name

Last Name

Address

City

State

Zip

SSN

DOB

Language

Gender

Gender Identity

Race

Guardian Contact

First Name	Last Name	Relationship	Phone

First Name

Last Name

Phone #

Relationship

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Request for Behavioral Health (Mental Health or Substance Use) Assessment and/or Linkage with Family Service League, Inc.

Requestor's Contact Information

Secondary Contact Information (i.e. if need to reach different staff member after hours, etc.)

Referral Information

Student's Information

Guardian Contact