WRHS Parent Request

Pediatric Behavioral Health

Client Information Form For School-Based Referrals
General Information
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Student Gender*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell Phone*
Student E-Mail*
Parent Name*

First NameLast Name
Parent Phone Number*
Parent Email (this one will be used for patient portal)*
Insurance

A credit card will be required to be placed on file for all copays/coinsurance and applicable charges will be run on the date of service
Insurance Company*

Apsotrophe HealthBlue Cross / Blue ShieldBMC HealthNetFallon HealthGICHarvard Pilgrim Health CareHealth Plans, IncUMRUnicareUnited Health CareSelf Pay
Policy Number
Subscriber Name
Subscriber DOB
Student's Primary Care Doctor *
WRHS Referring Counselor*

Please check if the following are of concern for your child.*

	Concerned	Not Concerned
Adjustment to change
ADHD
Anger
Anxiety / Worries / Panic Attacks / Fear
Autism Spectrum Disorder
Body Image Issues / Eating Disorder
Bullying
Chronic Pain / Chronic illness
Chronic Hair Pulling
Cyber Addiction
Grief / Loss
Juvenile Sexual Issues
LGBTQ Issues
Mood Swings / Depression / Sadness
Obsessive / Compulsive Disorder
Perfectionism
Relationship Issues (dating, friendships, family)
Self Esteem Issues
Sleep Disturbances
Parent / Child Relationship Issues
Planning for College
Psychosis
Suicide Attempt / Self Harm
Substance Abuse
Trauma
School Refusal / Significant Absences

Pediatric Behavioral Health