We’re glad you’re here!

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 605-444-7500.

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

Upload Parent Authorization Form

No file selected

Click or drag here to add files

Child's Information:

co9r6h9wxdqy

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?

How would you like us to contact you?

Email
Phone
Mail

School Based Counseling Referral

We’re glad you’re here!

Child's Information:

Parent/Guardian Information:

Referred By: