School Health Request Portal


SITE & PROVIDER INFORMATION:

 

Site/School Name:    

Is your site affiliated with a School-Based Health Center?      Yes           No 

If not, what best describes your site?       School               Health Care                Behavioral Health Care

Zip Code:    

Provider Name:    

Professional Discipline:    

Provider Email Address:     

Provider Phone Number: (In case a phone call is needed, what's the best number to reach you at work in the next few days?)    

CONSULTATION QUESTION:

Select all that apply:

 Diagnosis/Assessment

 Medication Intervention/Management

 Psychosocial Intervention/Management

 Disposition/Referral Questions

Gender of Client:       Male     Female

Age of Client: 

Is school grade appropriate to age?      Yes           No 

Brief description of presenting problem (including relevant past history of difficulties and treatment):

 Your request will be answered within 2 to 3 working days

If you have any questions or problems with this form, please call Flor Cano-Soto (505) 366-7607.