Halle Elementary

Your School-Based Therapist:

Brittany Berkley, LSW
216-386-8373

Sylvia Erikson-Blevins, LPC
440-325-9680

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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

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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

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