WRHS Parent Request

Pediatric Behavioral Health

Client Information Form For School-Based Referrals
General Information
Student Name

First NameLast Name
Student Date of Birth

MonthDayYear
Student Gender
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell Phone
Format: (000) 000-0000.
Student E-Mail
Legal Guardian Name

First NameLast Name
Legal Guardian Phone Number
Format: (000) 000-0000.
Legal Guardian email (for patient portal)
Other Legal Guardian Information (if applicable)

Will we obtain consent from both legal guardians as it is required to render mental health services to a minor
Second Legal Guardian Name

First NameLast Name
Second Legal Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance

A credit card will be required to be placed on file for all copays/coinsurance and applicable charges will be run on the date of service
Insurance Company
Policy Number
Subscriber Name
Subscriber DOB
Student's Primary Care Doctor
WRHS Referring Counselor

Please check if the following are of concern for your child.

Rows	Concerned	Not Concerned
Adjustment to change
ADHD
Anger
Anxiety / Worries / Panic Attacks / Fear
Autism Spectrum Disorder
Body Image Issues / Eating Disorder
Bullying
Chronic Pain / Chronic illness
Chronic Hair Pulling
Cyber Addiction
Grief / Loss
Juvenile Sexual Issues
LGBTQ Issues
Mood Swings / Depression / Sadness
Obsessive / Compulsive Disorder
Perfectionism
Relationship Issues (dating, friendships, family)
Self Esteem Issues
Sleep Disturbances
Parent / Child Relationship Issues
Planning for College
Psychosis
Suicide Attempt / Self Harm
Substance Abuse
Trauma
School Refusal / Significant Absences

Pediatric Behavioral Health