Health Yeah!

Referral Form

See disclaimer below for information on disciplinary and legal consequences for false referrals, bullying, and/or misrepresentation.

Name of Person Seeking Help

First Name

Last Name

School Name

Date of Birth (if known)

MM

DD

YYYY

Current Grade Level

Contact Information of Person Seeking Help

(###)

###

####

IF YOU ARE NOT THE PERSON SEEKING HELP

Please provide your name and contact information below.

First Name

Last Name

Relationship

If you listed 'Other' please provide your relationship below.

Phone Number

(###)

###

####

REASON(S) FOR SEEKING HELP OR REFERRAL

I am not feeling well.

Physically

Emotionally

I have an injury.

General questions.

Would prefer to discuss in person.

Yes

No

Additional Comments

NOTICE: Zero Tolerance for False Student Patient Referrals, Bullying, and Misrepresentation

At Health Yeah!, we are committed to maintaining the highest standards of integrity and respect within our student referral system. Submitting a false patient referral or making a false report about another student, especially in a healthcare or educational setting, is strictly prohibited and can have serious legal and disciplinary consequences.

Any false referral made with the intent to defraud, harm, or mislead may be considered fraud, harassment, or defamation, potentially leading to civil or criminal penalties.

All referral submissions are carefully monitored. Individuals found guilty of submitting false information or engaging in bullying will face severe consequences, including disciplinary action and legal prosecution to the fullest extent of the law.

We take these matters very seriously to ensure the safety and well-being of all students. Thank you for your cooperation in upholding a safe and supportive environment.