School Therapy Referral Form - Behavioral Health Clinic | Counseling & Therapy in Central Wisconsin

Email

School

Grade

If the student is being cared for by anyone but a biological or adoptive parent, a court order for legal custoday/guardianship must be reviewed and approved by Behavioral Health Clinic before services can be rendered.

Please send a copy of the court order with the referral, if possible. If there are any questions regarding the student's situation, please call us at 715-842-9500 to discuss.

Phone

Parent Primary Language

Referring Staff’s Name

Phone

If you checked "School Representative" box please fill out of a Release of Information for your school.

School Counseling Agreement Form - Current Clients