School Counseling Referral

SCHOOL REFERRAL FOR COUNSELING

Thank you for contacting REACH Restoration Counseling. Please complete the referral form below and click submit. Once we obtain the referral, we will contact the parent/caregiver of the child, by emailing or texting them a link to the intake and screenings needed to be completed to move forward. Included in the intake forms is a Release of information we ask the parent/caregiver to sign to allow REACH Restoration Counseling and the referring school to communicate about the child.

School Referral Form for REACH Counseling

* Indicates required field

REFERRING SCHOOL *

Person Submitting Referral *

Client Demographics

Name *

First

Last

Email *

Cell Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home or Work Number *

Client's age *

Client's Gender *

If other, preferred pronoun/s *

Is it ok to discuss scheduling via email? *

Yes No

Is it okay to leave a voicemail? *

Yes No

REASON FOR REFERRAL TO REACH COUNSELING. *

has the parent/caregiver been notified of the referral to REACH Restoration Counseling? *

Yes No

OTHER COMMENTS. *

Submit

PAPER COPY OF INTAKE AND SCREENINGS FOR SCHOOLS WHO PREFER TO SEND FORMS HOME WITH STUDENT

Paper Intake for Schools to send home to caregiver
File Size:	879 kb
File Type:	pdf

Download File

Paper Referral for Schools to Fax to REACH
File Size:	230 kb
File Type:	pdf

Download File

SCHOOL REFERRAL FOR COUNSELING

School Referral Form for REACH Counseling

RESTORING

EDUCATING

ADVOCATING

COLLABORATING

HOPE