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School Based Mental Health Referral Form
Complete and submit this form to refer a Des Moines Public School student for our school based mental health services in the school, billed through insurance.
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* Indicates required question
Student name:
*
Your answer
Student Date of Birth:
*
MM
/
DD
/
YYYY
Student Address (including city, state, zip):
*
Your answer
Parent or Legal Guardian name:
*
Your answer
Parent or Legal Guardian phone number:
*
Your answer
Parent or Legal Guardian email address:
Your answer
Is the contact person listed above a court appointed legal guardian?
Yes
No
Clear selection
Language spoken by student:
*
Your answer
Language spoken by parent/guardian:
*
Your answer
If student or parent/guardian speaks any language other than English, what is the BFL's name, email address, and phone number?
Your answer
School name
*
Samuelson
Downtown School
Cowles
Winterset High School
Lincoln High School
Merrill Middle School
Greenwood Elementary
Referral source:
*
Your answer
Referral source phone and/or email:
*
Your answer
Reason for referral:
*
Your answer
Family has agreed to the referral?
*
Yes
No
Submit
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