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Care Clinic Referral Form
CARE CLINICS ARE OPEN EVERY DAY THAT SCHOOL IS IN SESSION;
Referrals are processed according to severity; therefore, non-urgent referrals may not be seen until the next day.
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* Indicates required question
Email
*
Your email
Tell us about this referral:
*
I am referring myself
I am a staff member, referring a student
I am a parent/guardian, referring my child
Name of person Submitting this Form
*
Your answer
Cell Phone Number (for text/call) or extension of Person Submitting this Referral
*
Your answer
Last name of individual being referred
*
Your answer
First name of individual being referred
*
Your answer
SCHOOL LOCATION
*
ACADEMY
AREA TECHNOLOGY CENTER (ATC)
ASTRA
BLOOMFIELD ELEMENTARY
BLOOMFIELD MIDDLE
BOSTON SCHOOL
CENTRAL OFFICE
COXS CREEK ELEMENTARY
EARLY LEARNING CENTER
FOSTER HEIGHTS ELEMENTARY
HEARTLAND YOUTH VILLAGE
NELSON COUNTY HIGH
NEW HAVEN SCHOOL
OLD KY HOME MIDDLE
THOMAS NELSON HIGH
If you would like us to text the patient directly regarding this referral, please list their cell phone number here.
Your answer
What is the reason for this referral?
*
Your answer
If you would like to provide any additional information, please list it here.
Your answer
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