SCHOOL-BASED THERAPY REFERRAL FORM School staff or family members may refer students to GIFTS by completing the form below. Client Name * First Name Last Name Date of Birth * MM DD YYYY Client's School * Carroll Manor Chesapeake HS Deer Park MS Fort Garrison ES General John Stricker MS Halstead Academy Harford Hills ES Loch Raven HS Lyons Mill ES Millbrook ES Millford Mill Academy New Town HS Northwest Academy Owings Mills HS Pleasant Plains ES Randallstown ES Randallstown HS Seven Oaks ES Timbergove ES Timonium ES Wellwood International School Grade * Parent/Guardian Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Main Phone * (###) ### #### Email * Reason for Referral * Insurance * Insurance ID * Name of Policy Holder * Policy Holder Date of Birth * MM DD YYYY Referrer Name * First Name Last Name Referrer Title * Did the referrer speak to the parent/guardian about GIFTS services? * Yes No Date MM DD YYYY Thank you!
