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Referrer Information
Today's Date
Person Referring Family:
Position
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Administrator
Counselor
Evaluation Specialist
Interventionist
LSSP
Parent/Guardian
Parent Liaison
Prevention Specialist
Social Worker
Teacher
Other
Contact Number
Email Address
Student Information
Student's Name
Home Campus
Student's ID #
Student's Grade
Does student receive any Special Education Services
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Yes
No
Student's Birth Date
Students Ethnicity/Race
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Other
African American
American Indian
Asian American
Caucasian
Hispanic
Does the student have medical insurance?
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Yes
No
Type of insurance and company
Family Information
Parent/Guardian Name
For parent or For Guardian
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Parent
Guardian
If Guardian, is there legal documentation?
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Yes
No
Home Address
City
State
Zip Code
Phone Number
Cell/Work Number
Perefered alternate phone number
Parent/Guardian Language(s) Spoken
English
Spanish
Other
Primary Needs Expressed by Family
Individual, Family, Group Counseling
Parenting Class
Psychiatric Evaluation
Medicaid/CHIP Assistance
Substance Abuse Counseling
Other Needs(Brief Description)
Most Convenient FRC Site for Family
Please chose the most convenient site for the family:
No Preference
Forest Oak (3250 Pecos St., 76119)
Riverside (1550 Bolton St., 76111)
Northside (at J.P. Elder MS-2011 Prospect Ave., 76164)
Western Hills (8340 Mojave Trail, 76116)
Send Referral
Date referral was discussed with the family and family informed referral source will be contacted by FRC Staff.
All fields must completed in order to submit referral – Thanks!