Form Center

2. Today's Date*
   Today's Date
4. Student's Name*
5. Date of Birth*
7. Sex assigned at birth*

   1. Male
   2. Female
   3. Choose not to disclose
8. Gender identity*

   1. Male
   2. Female
   3. Trans Man
   4. Trans Woman
   5. Non-binary
   6. Other
   7. Choose not to disclose
9. Pronouns
11. Student's preferred name
12. Student's current grade*
14. Referring School*
15. Student's Guidance/Adjustment Counselor*
17. Person submitting referral*
18. Contact phone number*
20. Email address of person submitting referral*
24. Name of parent(s)/guardian(s)*
25. Contact phone number*
27. Parent(s)/guardian(s) email address*
28. Does student live with parent(s)/guardian(s)*

    1. Yes, parent
    2. Yes, guardian
    3. No
30. Student's home address*
31. City*
32. Zip Code*
34. Is this student willing and able to sit and engage in a therapeutic session on a weekly basis for at least 30 minutes?*

    1. Yes
    2. No
35. Student's insurance plan*
37. Does this student have an IEP?*

    1. Yes
    2. No
    3. In-progress
38. If yes, please elaborate on the student's needs.
40. Is this student in any specialized program?*

    1. Yes
    2. No
    3. In-progress
41. If yes, please list program(s).
43. Does this student have any other support services in place?*

    1. Yes
    2. No
    3. In-progress
44. If yes, please list (i.e. therapeutic mentor, speech, OT, VIPS mentor, BBBS, DCF).
46. Does this student have any known medical conditions?*

    1. Yes
    2. No
    3. Unknown
47. If yes, please list medical condition(s).
49. Reason for referral/presenting issues*
51. Other comments or specifics about student's needs
53. We request that parent(s)/guardian(s) of minors be verbally notified prior to submission of the referral. Has this parent/guardian been notified?*

    1. Yes
    2. No
54. We request that all clients enroll in counseling voluntarily. Have you confirmed that this student will attend voluntarily?*

    1. Yes
    2. No
56. As visitors to your building, we rely on you to arrange a confidential meeting space. Do you agree to secure space for these sessions?*

    1. Yes
    2. No
57. Would this student prefer sessions at the Falmouth Human Services office (based on social worker availability)?*

    1. Yes
    2. No
59. Please list this student's best availability (day/time) to be seen for counseling (based on social worker availability).*
61. Due to our availability to only provide up to 12 sessions, we require that the client be on a waitlist elsewhere for longer-term counseling. Is the student on a waitlist elsewhere?*

    1. Yes
    2. No
62. If yes, please list where student is on a waitlist.
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

* indicates a required field