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School Health Request



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?)    


Select all that apply:


 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.