Seven Counties Services Referral Form
Fill out form if you would like to refer a student or your child for counseling services with Seven Counties
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If you are school staff the parent/ guardian must give verbal permission school personnel for Seven Counties Services (SCS) to contact them.  All areas of this form must be completed and verified before the SCS Provider can contact the family.  Thank you.
Date *
MM
/
DD
/
YYYY
Student First and Last Name *
Student Date of Birth *
Parent/ Guardian Name *
Parent Phone Number(s) *
Student Address *
Students Grade *
Name of Students Teacher *
Medical Card (Member ID # required) *
Behavior Concerns *
Students Strengths *
Special Needs/ Learning Problems (please indicate if student receives ECE/Speech/OT services at school) *
Person Making the Referral *
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This form was created inside of Jefferson County Public Schools.