Inquiries and Referrals for PATH Counseling Program

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Through our Providing Access to Healing (PATH) program, counseling services are offered during the school day for students enrolled in the Sioux Falls School District.

School counselors can refer a student by asking parents to complete the form below. If you have questions, please call us at 605-444-7643.

With the submission of the online form below, please include a signed Parent Authorization Form.

Upload Parent Authorization Form

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Child's Information:

Child's First & Last Name

Date of Birth

Gender

School

Grade

Race/Ethnicity

Child/Family Primary Language

Current Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Why would this child benefit from in-school counseling services?

Insurance or Medicaid Eligibility, if Known

Parent/Guardian Information:

Parent/Guardian or Custodial Person Name

Parent/Guardian Phone

Parent/Guardian Email

Name of Other Significant Caregivers/Case Workers/Counselors

Other Caregivers/Case Workers/Counselors Phone

Other Caregivers/Case Workers/Counselors Email

Current Barriers to Care in Community

Transportation
Parent work schedules
Parent awareness
Lack of availability at community providers
Limited financial resources
Other

If Other, please explain:

Referred By:

Referral/Contact Person

Referral/Contact Agency

Referral Phone Number

Referral Email Address

Date of Referral

What else would you like us to know?

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How would you like us to contact you?

Email
Phone
Mail

School Based Counseling Referral

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Child's Information:

Parent/Guardian Information:

Referred By: