School Referral FormSTUDENT First name*STUDENT Last name*PARENT/GUARDIAN First name*PARENT/GUARDIAN Last name*SCHOOL COUNSELOR Name*PARENT/GUARDIAN email*PARENT/GUARDIAN Phone*STUDENT Zip code*PARENT/GUARDIAN Insurance type*STUDENT Birthday*MM slash DD slash YYYYSTUDENT Gender*MaleFemaleWhy are you are seeking therapy?*Have you seen a therapist before?*YesNoAre you currently seeing a psychiatrist or medical doctor for psychiatric medicines?*YesNoAge of individual seeking treatment?*Δ