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School Referral Form
Empowerment Counseling and Consulting 
Phone: 901-206-5604
Fax: 901-205-0562
Email: info@ecc-memphis.com
*Completion of this form does not guarantee an appointment. Therapist availability, clinical fit, and cost of services have to be reviewed before assignment. If you don't hear from us in 5-7 business days, please give us a call. 
Email *
Date *
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Your Email  *
Referral source (your name and role)  *
Is the parent aware of and agreeable to this referral?  *
Is this referral urgent?  *
Client First Name *
Client Last Name *
Gender *
Age *
Date of Birth *
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DD
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School Attending *
Grade *
Parent/Guardian First Name *
Parent/Guardian Last Name
 *
Address  *
City/Sate/Zip *
Primary Phone *
Parent Email Address *
Atl. Phone 
Insurance *
Presenting Problem *
Additional Comments
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