SWIFT Family Focus Referral Form
SWIFT is available to students who have the Oregon Health Plan, we are not able to bill other insurance. We do have a private pay option for interested families.
The following questions focus on the eligibility requirements for participation in the program. Please answer each question the best you can for the potential student.
Please note: SWIFT is not a program to stabilize students in crisis.
Thank you,
The SWIFT Team
Today's Date *
What is your role? *
Teacher
School Counselor/ Psychologist
School Administrator
Parent/ Guardian
Other
Parent's Name *
Parent's Phone Number
Parent's Email
Parent's Preferred method of contact
Student's legal first and last name *
Student's pronouns
Student's date of birth
Student's sex assigned at birth
Is this student on the Oregon Health Plan (OHP)?
Yes
No
Thank you for completing the SWIFT Screener Questionnaire. A copy of the form will be emailed to you. The SWIFT Program Team will review this form and follow up with you soon with an update.
If you have questions please contact SWIFT Program Team swift@oslc.org.