School Counseling Referrals - Tranquility Wellness LLC

Fields marked with * are required

Student's Name *

Year Level *

Referral Source *

External Agency Referral? Please state the organisation.

Referer's Name *

Phone Number *

Email

Other reason for referral (Please state below)

Please provide further information regarding this referral: *

Desired wellbeing outcome: *

Relevant History (Is the child on any medications? Does the child have a diagnosis? Is there a history of mental health illness within the family?) *

Are any other services/organizations involved with this child or family? *

Has the child or family had any Department of Children and Families (DFS) involvement? *

Parent Consent? Parents will be contacted regarding this referral. Individual Counselling can only take place with parental/guardian consent. *

Is the student aware of the referral? *

I agree toTranquility Wellness LLC Privacy and Confidentiality Disclosure *