Southwest Behavioral & Health Referral Form

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Counseling referral for SWBH Clinician

Southwest Behavioral & Health Services

PLEASE COMPLETE ALL SECTIONS. FAILURE TO DO SO WILL DELAY CONTACT WITH YOUR STUDENT.

Name of the person completing this form. *

Contact number for the referral person *

Student Name *

Student Date of Birth *

YYYY

Student Grade *

Parent Contact Information: Name, Phone and/or email *

Date Person Referring Contacted the Parent to get more information on observed concerns. *

YYYY

Reason for Referral *

Depression

Anger

Grief and Loss

Self-Harm

Isolated / Withdrawal

Social/Relational

Suicidal

Behavioral Risk Taking

Substance Use / Abuse

Other:

Brief Supporting Information for Referral Reason

ADMINISTRATIVE USE ONLY

Date referral Received:

Date of First Contact:

Date of Intake

Parent Declined Services Date:

Submit

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