School and Agency Counseling Referral

SCHOOL & AGENCY 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 & Agency 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

SCHOOL & AGENCY REFERRAL FOR COUNSELING

School & Agency Referral Form for REACH Counseling

RESTORING

EDUCATING

ADVOCATING

COLLABORATING

HOPE