Referral Form

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Referral Form

Please complete the below form to begin the referral process.

At this time, we are able to take all referrals for kids that attend Elizabethtown Independent Schools. Prospective clients do not have to receive therapy at school during the school day and can opt for afternoon appointments, telehealth or home based therapy.

Because of our school based obligations, we are not able to accommodate all referrals. We will notify you by email within 48 hours if we are able to accommodate your referral and if we can, to begin the scheduling process. If we are unable to take on your referral, we will email you to inform you of this and provide a list of other potential therapy options. Please ensure that the email address you provide is one that you regularly check.

Name of individual being referred *

Date of birth *

YYYY

Grade *

School

Panther Academy

Morningside

Helmwood

TK Stone

EHS

Valley View

Homebound/PoL

Other:

Clear selection

Parent/guardian name *

Address *

Phone number *

Does the referral have involvement with social services or an active court case of any kind? *

Do you have any preference for the primary provider? *

Christopher Longoria, LCSW, RPT-S

Krista Mitchell, LCSW, RPT

Kyla Claycomb, CSW

Jen Murphy, LPCA

Hannah Kuhn, CSW

Corinsa Smith, LMFTA

Shelby Pennick, LPCC (Telehealth only)

Abbe Kessinger, LPCA (TK/EHS Only)

For EIS kids - Whoever is primary at my child's school/referral's school

No preference

Required

What services are you interested in/do you feel would benefit the referral?

Individual therapy

Family therapy

Group therapy

Targeted Case Management

Community Support Services

Psychological Testing

Psychiatric Medication Management

Is the child being referred currently in foster care? *

Yes

I am/the individual is an adult

Reason for referral *

Insurance Type *

Self-pay

Aetna

Anthem BCBS

Cigna

Humana

Medicaid (Passport, Aetna BH, Humana, United Healthcare, Anthem)

Optum

Tricare

UMR

Other:

Your name *

Relationship to person being referred *

Self

Parent or Guardian

School personnel

Medical Professional

DCBS Worker

Sunrise personnel

Other:

Your email address *

Your phone number *

Have you spoken to the guardian and informed them that the referral would be made?

Yes

I am the parent/guardian

Clear selection

Submit

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