Pediatric Behavioral Health
Client Information Form For School-Based Referrals
General Information
Student Name
*
First Name
Last Name
Student Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Student Gender
*
Please Select
Male
Female
Nonbinary
Transgender
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Cell Phone
*
Student E-Mail
*
Parent Name
*
First Name
Last 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 Health
Blue Cross / Blue Shield
WellSense (BMC)
Carelon (Fallon)
Harvard Pilgrim Health Care
Health Plans, Inc
UMR
WellPoint (Unicare)
United Health Care
Anthem
Tufts
Mass General Brigham
Self 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
Description of Presenting Problem
*
Are Both Parents Aware of the School Referral for School based therapy?
*
Please Select
Yes
No
Please describe any concerns either parent may have about this referral
*
Submit
Date:
-
Month
-
Day
Year
Should be Empty: