Counseling Referral Form - Kids' Turn San Diego

Please fill out the following information on the child and our office will contact you within 3 business days.

Your name:*
Your phone number:*
Your email address:*
Your address:*
Name of child being referred:*
Child's birthdate and age*
MM slash DD slash YYYY

mm/dd/yyyy and age
Child's gender:*
Child's school:
Name of child's other parent:*
Child's other parent's phone number:*

We require consent by both parents for children to receive counseling at Kids' Turn San Diego, so we must have contact information. Please provide either a phone number or email. It is ok to write NA on the other question.
Child's other parent's Email address:*

We require consent by both parents for children to receive counseling at Kids' Turn San Diego, so we must have contact information. Please provide either a phone number or email. It is ok to write NA on the other question.
Custody arrangements with each parent:
Please tell us about your concerns and why you think your child needs counseling. Please be specific.*
Counseling sessions are provided through Telehealth. Is your child able to manage a computer on their own or do they need assistance? Has your child been successful with remote learning? Is there a confidential location in your home that your child will be able to use for counseling sessions?*
What is the best day(s)/time(s) for your child to participate in counseling sessions?*
Has your family attended a Kids' Turn San Diego Family Workshop? If so, when did you attend?*
Who should we contact to schedule the first meeting?*
How did you hear about the counseling program?*