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Social & Emotional Care Referral
School Referral Information
Dafe of Referral
Referring Personnel Name
Last Name
Email
Title
Phone
How did you hear about Harvest Family Life Ministries?
Preferred method of contact
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Recipient Personal Information
First Name
Last Name
Place of Residence
Address
School Name
School District
School Grade
Age
Sex
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DOB
Insurance Provider
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Social Security #
Is the recipient currently taking medication for mental health issues?
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Medicaid #
Date of last hospitalization (if)
Primary Care Physician/Phone Number
Is the recipient currently enrolled with another mental health provider? (If yes, please provide the facility name and last date seen)
Presenting Issue(s):
Do you have any additional documents that you believe might be helpful to our team? (Ex: Report Card, Previous CANS Assesment, Psych Evaluation)
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