Guidestone School Services Referral Form (For Parent)
Our School Services program works with children and adolescents to provide mental health and other support services in the school environment, family home or a community setting. Innovative programming is custom designed to meet the needs of each school and can include individual, group, parent and family services.

Our mental health professionals provide behavioral health assistance within the school setting, allowing them the opportunity to consult with teachers and other school professionals to help track the client’s progress. Our counselors also maintain connections with parents and families to help keep the families connected to the child’s academic environment. A variety of counseling services are available based on the needs of the client and family.

If you would like to receive FREE services, please fill out as much information as you feel comfortable providing.
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Student First Name *
Student Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Race (select all that apply) *
Required
Address *
Grade *
Gender *
Social Security Number (You may choose not to provide)
THIS IS A FREE SERVICE. SSN is the most commonly used means to identify patients and their records and will allow counselors to connect to earlier patient history if available.
Parent Name (Last, First) *
Medical Coverage  (You may choose not to provide)
THIS IS A FREE SERVICE and having insurance IS NOT REQUIRED, however, knowing insurance information allows our counselors to connect you to additional services that may be provided to all patients.
Clear selection
Insurance Plan Number  (You may choose not to provide)
Reason for Referral (check all that apply) *
Required
Describe your concerns: (Include academics, behavior, family, health, hygiene, social & emotional at home or in school)
Interventions (Strategies used; level of effectiveness and results, used at home or in school)
Submit
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