Garrett Morgan High School

Garrett Morgan High School Counseling Referral

Your Centers School-Based Therapist:

Ryan MacKay, LPC
216-474-3278

Demographic Information for Potential Client

First Name(Required)

Middle Initial

Last Name(Required)

Parent/Guardian Full Name(Required)

Student’s Date of Birth(Required)

Social Security Number (SSN)

Street Address(Required)

City(Required)

State(Required)

ZIP Code(Required)

Phone Number(Required)

Parent/Guardian Email

Insured?(Required)

Type of Insurance

Member ID/Subscriber ID

Please provide any additional information about the potential client and their care:

Client Gender

Parent/Guardian Gender

Client Race

Parent/Guardian DOB

Client Ethnicity

Parent/Guardian SSN

US Citizen?

Reason(s) for Referral – Problems/Concerns related to: (Please check all that apply.)

Note any major changes in the previous 6 months

Parental Consent

NOTE: This form cannot be submitted without parental/guardian consent

Have you contacted the parent/guardian about your concern?(Required)

Date of contact

Date of consent(Required)

Explain the outcome of parent contact

Best time to pull student during school hours

Referral Source

Please provide your information so we may contact you regarding this referral:

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Title(Required)

Phone

This field is for validation purposes and should be left unchanged.

Circle Health Services Tax ID #23-7078501 | Cleveland Christian Home Tax ID # 34-0733131 | The Centers for Families and Children Tax ID # 23-7084455

This website is supported, in part, by Grant Number 05CH011948 from the Office of Head Start within the Administration for Children and Families, a division of the U.S. Department of Health and Human Services. Neither the Administration for Children and Families nor any of its components operate, control, are responsible for, or necessarily endorse this website (including, without limitation, its content, technical infrastructure, and policies, and any services or tools provided). The opinions, findings, conclusions, and recommendations expressed are those of The Centers and do not necessarily reflect the views of the Administration for Children and Families and the Office of Head Start.

Circle Health Services receives HHS funding and has been awarded Federal Public Health Services (OHS) deemed status with respect to certain health-related claims, including medical malpractice claims, for itself and its covered individuals.