Near West Intergenerational School

Near West Intergenerational School Counseling Referral

Your Centers School-Based Therapist:

Ryan MacKay, LPC
216-474-3278

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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

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)