School Referral to Family Counseling Service

Phone
This field is for validation purposes and should be left unchanged.
Please Attach Consent for Exchange of Information Between FCS and the School District*
Max. file size: 256 MB.
Your Name*
First Last
School Name
Your Phone Number
Your Email Address*
Requested Treatment Setting
Student Name
First Last
Grade Level
Student Primary Language
Student D.O.B.
Student Address
Street Address Address Line 2 City ZIP Code
Student Parent/Guardian Name(s)
Parent/Guardian Primary Language
Has the Parent/Guardian Been Notified of Referral?
Have you informed the student's parents that FCS will bill their insurance, if available?
Parent/Guardian Phone Number
Reason for Referral
Hours Available for Therapy During the School Day*
Please Note Any Known Student Preferences (Male/Female, Religious Preferences, Morning or Afternoon, Language, Etc.)
CAPTCHA

Come by for a visit!

We’re conveniently located right in downtown Aurora.

Call Us:

(630) 844-2662

Follow Us on Facebook:

FB.com/FCSAurora

Visit Us:

70 S. River Street Aurora, Illinois