Puritas Community ElementaryThank 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 Web Site Organization confirmation By proceeding, I acknowledge that I am affiliated with Puritas Community Elementary Demographic Information for Potential Client First Name * Middle Initial Last Name * Parent/Guardian Full Name * Student’s Date of Birth * Social Security Number (SSN) Street Address * City * State * ZIP Code * Phone Number * Parent/Guardian Email Insured? * Yes No Please provide any additional information about the potential client and their care: Client Gender Male Female Non-Binary Client Race White Black/African American Asian Alaskan Native American Indian Native Hawaiian Unknown Client Ethnicity Hispanic/Latino Non-Hispanic or Latino Unknown US Citizen? Yes No Unsure Parent/Guardian Gender Male Female Non-Binary Parent/Guardian DOB Parent/Guardian SSN Reason(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 Dramatic change in behavior Worries Daydreams Grief Fears Sadness Always tired Motivation Inattentive Withdrawn Cries easily for age Self-image/confidence Non-touchable/pulls away Nervous/anxious Perfectionist Aggression/Anger Swearing Fighting Lying Bullying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.) Other Note any major changes in the previous 6 months Have you contacted the parent/guardian about your concern? * Yes No Acknowledgement of consent The parent/guardian has consented to moving forward with this referral NOTE: This form cannot be submitted without parental/guardian consent Best time to pull student during school hours Referral Source Puritas Community Elementary Puritas Middle School Westside Community School of the Arts Please provide your information so we may contact you regarding this referral: First Name * Last Name * Phone * Email * Title * Your Centers School-Based Therapist:Chris CudaPuritas Community Elementary 216.971.3641