School Partnerships Request Form

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School Partnerships Request Form

School Partnerships Request FormAdmin2022-12-21T20:20:30+00:00

School-Based Referral Form

School-Based Therapy is an Embedded Program in certain schools where KESMA Flame Lily has an established and coordinated relationship to provide mental health therapy to students during the school day. If you are looking for Skills Work for the student, please complete the CTSS Referral for Home-Based Services. We only work through schools that are on our list. Referrals can be made by either School Support Staff or a parent/legal guardian.

To make a referral, please complete the following form. A member of the KESMA Flame Lily team will reach out if there are questions. Please trust that if you receive an automated notification, your referral was received and that we are tracking it and will reach out to coordinate scheduling.

Who is making this referral?

Which school does the child attend? *If child's school is not listed, we do not offer school-based therapy there. Please reach out directly to your school for resources.

School Contact or School Social Worker

School Contact or School Social Worker Phone Number

School Contact or School Social Worker Email *

Child's Full Legal Name

Child's Preferred Name *

Child's Date of Birth

Address *

Street Address Line 2 *

City *

State / Province *

ZIP / Postal Code *

Country

Parent/Guardian 1 Name

Parent/Guardian 1 Phone Number *

Phone Number *

Parent/Guardian 1 Email (If applicable) *

Parent/Guardian 2 Name

Parent/Guardian 2 Phone Number *

Phone Number *

Parent/Guardian 2 Email (If applicable) *

Language Preference *

Interpreter Needed?YesNo

Reason for Referral

Reason for Referral *

* Before KESMA Flame Lily Family Services can begin providing services to any client, we MUST have complete and correct insurance information and an active insurance plan. Any missing information will result in a delay of processing and services. Your attention to this is appreciated.

Insurance Company *

Group Number *

ID Number *

Who is the policy holder for your insurance plan? Please note: unless child's insurance plan is through Medical Assistance, the policy holder will be a relative.

How did you hear about us?

Internet Search (Google)Friend or Family MemberAnother Provider (ie. Doctor, case manager)An online advertisement (Facebook/YouTube)Other Media (i.e. radio or TV)NewsletterAt a Community Event (ie. resource fair, presentation)Other

As soon as we receive a referral, KESMA Flame Lily Staff will review it and check for complete information. Incomplete information will add time to processing. Thank You!