Near West Intergenerational SchoolThank you for reaching out to The Centers about a potential referral for services. Please enter referral information below and a member of our team will be in touch with you soon.Counseling Referral Affiliation confirmation(Required) By proceeding, I acknowledge that I am affiliated with Near West Intergenerational School(Required)Demographic Information for Potential ClientFirst Name(Required)Middle InitialLast Name(Required)Parent/Guardian Full Name(Required)Student’s Date of Birth(Required) Month Day YearSocial Security Number (SSN)Street Address(Required)City(Required)State(Required)ZIP Code(Required)Phone Number(Required)Parent/Guardian Email Insured?(Required)YesNoType of InsuranceMember ID/Subscriber IDPlease provide any additional information about the potential client and their care:Client GenderMaleFemaleNon-BinaryParent/Guardian GenderMaleFemaleNon-BinaryClient RaceWhiteBlack/African AmericanAsianAlaskan NativeAmerican IndianNative HawaiianUnknownParent/Guardian DOB Month Day YearClient EthnicityHispanic/LatinoNon-Hispanic or LatinoUnknownParent/Guardian SSNUS Citizen?YesNoUnsureReason(s) for Referral - Problems/Concerns related to: (Please check all that apply.) Dramatic change in behavior Worries Daydreams Grief Fears Sadness Always tired Motivation Inattentive Withdrawn Cries easily for age Self-image/confidence Non-touchable/pulls away Nervous/anxious Perfectionist Aggression/Anger Swearing Fighting Lying Bullying Disrespectful Defiant Hurts self Impulsive Overactive Easily distracted Chews (paper/clothes/hair) Makes Odd Sounds Stealing Destruction of Property Sexual Acting Out Peer Relationships Social Skills Personal Hygiene Family Concerns Academics Absences Tardy Poor organization Completion of Assignments Drop out risk (H.S.) OtherNote any major changes in the previous 6 monthsParental ConsentNOTE: This form cannot be submitted without parental/guardian consentHave you contacted the parent/guardian about your concern?(Required)YesNoDate of contact Month Day YearAcknowledgement of consent The parent/guardian has consented to moving forward with this referralDate of consent(Required) Month Day YearExplain the outcome of parent contactBest time to pull student during school hoursReferral SourceNear West Intergenerational SchoolOtherPlease provide your information so we may contact you regarding this referral:First Name(Required)Last Name(Required)Phone(Required)Email(Required) Title(Required)CommentsThis field is for validation purposes and should be left unchanged. Your Centers School-Based Therapist:Jaclyn GormanNear West Intergenerational School 216.434.2040