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Near West Intergenerational School Counseling Referral (Private Insurance)

Your Centers School-Based Therapists:

Kristie Persson, LPCC-S, ATR
440-332-4603
 
Randy Lindemann, LISW-S
216-325-9517

Demographic Information for Potential Client

Student’s Date of Birth(Required)

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

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

Parental Consent

NOTE: This form cannot be submitted without parental/guardian consent
Date of consent(Required)

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

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