School Referral

Honey Lake Clinic has the right people to help you start your journey to wholeness. We’re ready to help.

School Referral Form

STUDENT 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 YYYY
STUDENT Gender*
- Male
- Female
Why are you are seeking therapy?*
Have you seen a therapist before?*
- Yes
- No
Are you currently seeing a psychiatrist or medical doctor for psychiatric medicines?*
- Yes
- No
Age of individual seeking treatment?*