sbcreferral.christianfamilysolutions.orgSchool-Based Counseling Partnership Program Referral Form - Christian Family Solutions

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Yes No Gender: * Select One Male Female Student’s address: * Address Line 1 Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Is the student 14 years old or older? * Yes No Students age 14 and older in are required to sign the informed consent. Student’s email address * Student’s email address We are required to obtain informed consent from the student’s parent or legal guardian. If you have guardianship papers on file, please submit them to us at the end of this form. If we do not have the correct name and contact information for the parent or guardian, it may cause a delay in service. Name of parent or guardian: * First Last Phone of parent or guardian: * Ok to leave a message? * Yes No Email for parent or guardian: * Previous Next The Challenges Please give a brief summary of the reason for the referral: * Has the referral talked about ending his/her life? * Select One Yes No If the student has discussed ending his/her life please consider the safety of the student and whether immediate assistance through a local hospital or emergency facility is needed. Are you aware of any current or past mental health treatment for this referral? * Select One Yes No Please describe: * Has the parent or guardian been contacted regarding the need for counseling services? * Select One Yes No Previous Continue Tell us how the parent or guardian would like to pay for services Referral agents from schools may not have this information available. Christian Family Solutions staff will contact the parent or guardian to obtain their payment information. For students with commercial insurance or an inability to pay, Christian Family Solutions will provide an initial set of counseling sessions at no cost through our Teen Counseling Endowment Funds . Choose a payment method: * Select One I don’t know Private Pay Insurance Health Insurance Plan Name: Are you covered by a Medicare or Medicaid plan? Select One Yes No Subscriber’s Name: Subscriber’s date of birth: MM 1 2 3 4 5 6 7 8 9 10 11 12 DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Subscriber’s or Member ID Number: Group Number: Employer Name: Verification / Customer Service Phone Number: File Attachments: Click or drag files to this area to upload. You can upload up to 3 files. If you’d like to attach a file for this referral, please attach the file here. Collateral material may include a health consent form for an international student, legal guardian paperwork, health insurance information, or other notes or forms you’d like the counselor or our intake staff to have. Attachment must be in .pdf format. To protect privacy, all of the information you have entered is encrypted and stored securely. After you submit this information, a Christian Family Solutions representative will contact the student’s parent or guardian to obtain informed consent and then an appointment will be scheduled. Name * First Last Previous Submit Christian Family Solutions is an independent, non-profit agency that provides professional Christian counseling services and care for seniors. Our services are made more accessible to those in need through the generosity of our donors. HEALING AND HELPING PEOPLE IN NEED. Contact Details Corporate Address W175 N11120 Stonewood Drive Germantown, WI 53022 Corporate: 888-685-9522 Counseling: 800-438-1772 Counseling Fax: 262-345-5562 info@wlcfs.org Important Links COUNSELING CARE & SERVICES THE GARDENS OF HARTFORD CONTACT CAREERS GIVE Wisconsin Lutheran Child & Family Service, Inc. ©...