Paulding County School Referral Form

Please correct the errors described below.

The Northrop Connection, LLC

Name of Student

Name of Person Completing Form

Email address of person completing form

Name of Parent/Legal Guardian Who Can Make Medical Decisions for Student

Parent/Guardian's Phone Number

Where does the student prefer to receive services?

Parent/Guardian's Email address

Parent/Guardian's Preferred Method of Communication

Call Text Emal

Student's Grade

What is the student's insurance?

What are some areas of concern with this student?

Depressed Mood

Anxious Mood

Problems with Attention or Concentration

Concern about Self-Harm

Concern about Substance Use (tobacco included)

Social Impairments

Other, please explain.

Student's Date of Birth

What else would you like us to know?

Thank you for completing this appointment request! Our staff will reach out to the student's parent or legal guardian within 2 business days of completion of this form. Please reach out to us directly at 678-332-7955 if you have any questions!

Your information will be encrypted.

The Northrop Connection, LLC

Compassionate Mental Health Care

678-332-7955
www.thenorthropconnection.com
702 W MEMORIAL DR, DALLAS, Georgia, 30132, United States

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