Student Needs Request Form

Student Needs Request Form

Submit this form for connection with multiple Rogue Community Health services such as Behavioral Health, medical, dental, OHP assistance and/or the Youth Resource Navigator for connection with community resources.
Student Name:*

Last NameFirst Name
Student Age*
Student Date of Birth:*

MonthDayYear
Date
Student Sex:*

FemaleMaleOther
Student Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone numbers (select all that apply):*

Student Phone NumberParent/Guardian Number
Student Phone:*
Please enter a valid phone number.
Parent/Guardian Name:*
Parent Phone:*
Please enter a valid phone number.
School:*
Preferred Language:*

EnglishSpanishOther
Student/Family Needs (Please check all that apply):*

Counseling/Behavioral HealthAddiction/RecoveryHealthcare (Medical, Dental, Vision)Health Insurance/OHPHousing/ShelterFoodTransportationChildcareSafety/AdvocacySuppliesLegal AssistanceOther
Does student endorse self harm?*

YesNoUnknown
Does student endorse suicidal thoughts?*

YesNoUnknown
Is student receiving counseling services elsewhere?*

YesNo
If so, where?*
Main Concern for Student/Family, Contributing Factors or Other Important Information:
All student needs referrals sent via this form should be made with informed consent, meaning that based on the age of consent for requested services, either the student or parent/guardian should be aware of and agree to referrals sent on their behalf. Conversations should be had with consenting students or parent/guardians prior to referrals being sent.

Students 14 or older may consent to their own behavioral health and/or drug and alcohol treatment.

Students 15 or older may consent to their own medical and dental care and/or referrals to social services.

For students younger than the ages above for each specific service type, the parent/guardian must provide consent for those services.
Does the student know this referral has been made?*

YesNo
Does the parent/guardian know this referral has been made?*

YesNo
Referral Source Contact Information
Name of Referral Source:*
Relation to referred*
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Best time(s) to connect:
Referral Identifier*
Please use this to create a unique referral identifier to keep track of your own referrals. Youth Resource Navigator can refer to this identifier when giving outcome updates to school staff. Please do not use any Personal Identifying Information (PII) such as student names, phone numbers, ect.
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Student Needs Request Form

Referral Source Contact Information