BIE BHWP Referral Form

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Please note that this form will be completed during a virtual referral intake session and completed forms should not be sent to the BHWP at any time to ensure the protection of your confidential information.

Request for BIE Behavioral Health and Wellness Program (BHWP):
☐  Counseling
☐  Resources

Referred by (check all that apply):
☐  Self 	 ☐Custodial parent/Legal Guardian 
☐  Counselor ☐  Other ____________________
☐  Teacher 
Referral Name and Contact Information: _________________________________________

Client’s Full Name: __________________________________________________________
Preferred Name: ______________________________________________________________
Custodial Parent/Legal Guardian Information: 
If under the age of 18, parent/legal guardian's name: ______________________________

Date of Birth: ________________________________________________________________
School Affiliation: ___________________________________________________________
Department Affiliation (if adult) ______________________________________________
Tribal Affiliation or Tribal Enrollment: _________________________________________

Mailing address (if minor, parent/legal guardian address): 
Address/P.O. Box: ____________________________________________________________
City: ____________________________________________      State: ____________________
Zip Code: ____________________________________________________________________

Physical address (if different from mailing address): 
Physical Address: _____________________________________________________________
City: ____________________________________________      State: ____________________
Zip Code: ____________________________________________________________________

Contact information (if minor, parent/legal guardian phone): 
Home Phone: (______) __________________ Cell Phone: (______) ____________________ 
Email: _________________________________ 




Preferred phone for contact: 
☐  Home  ☐  Cell 

If a cell phone, do you agree to receive text messaging regarding appointment times, emergency contact, or other necessary contact times? 
☐  Yes    ☐  No 
Status 
☐  Student 
      Grade Level __________
☐  Staff Member/Faculty 
☐  Student Family Member 
 
Gender/Orientation: 
☐  Male 
☐  Female 
☐  Self-identify as ______________
☐  Prefer not to respond 

Preferred Pronouns (he/him, she/her, they/them): 
 
Emergency Contact Information: 
Emergency Contact Name: _____________________________________________________
Emergency Contact Phone Number: (_______) ____________________________________
Emergency Contact relationship to client: ________________________________________
 
Secondary Emergency Contact Name: ____________________________________________
Secondary Emergency Contact Phone Number: (_______) __________________________
Secondary Emergency Contact relationship to client: _______________________________
  
Reason for Referral: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

As applicable:
Local or preferred hospital or emergency room nearest your physical location: 
Hospital or ER address: ________________________________________________________
Hospital or ER Phone Number: _________________________________________________
  
Local EMS, Law Enforcement Department or Community Health Office: 
EMS Contact Number: _________________________________________________________
Local Law Enforcement Contact Number: ________________________________________
Community Health Office: _____________________________________________________


Privacy Act Statement: This information is collected pursuant to the provisions of the Privacy Act of 1974, as amended, under the Department of the Interior (DOI) Privacy Act system of records, INTERIOR/BIE-02, Behavioral Health and Wellness Program.  This system helps the Bureau of Indian Education (BIE), Behavioral Health and Wellness Program (BHWP), provide immediate behavioral health crisis support, clinical counseling services, crisis care coordination, and communication with the client and appropriate points of contact for referrals and continued service delivery or emergency care. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b), all or a portion of the records or information contained in this system may be disclosed outside DOI as a routine use pursuant to 5 U.S.C. 552a(b)(3).

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide indigenous focused, evidence-based, and trauma-informed behavioral health and wellness services/resources for students and staff at all Bureau-funded programs, departments, and institutions including Bureau operated schools, Tribally controlled schools, post-secondary institutions, and Tribal colleges and universities. Your response is voluntary, and we will not share the results publicly. We may not conduct, or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this form and assigned OMB Control Number 1076-0122, which expires ##/##/####.  

Estimated Burden Statement: We estimate this form will take BHWP staff, via staff and/or student virtual referral intake interviews, 30 minutes to complete, including time needed to read instructions, gather information, complete, and submit the form. Please note that this form will be completed during a virtual referral intake session and completed forms should not be sent to the BHWP at any time to ensure the protection of your confidential information. You may submit comments on any aspect of this information collection to the Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.