Please Select the Student's School* Kingsland Public Schools Pine Island Public Schools Rochester Alternative Learning Center Demographic/Financial InformationThank you for your inquiry regarding Zumbro Valley Health Center Psychotherapy through School-Linked Mental Health services. Psychotherapy services are typically covered through health insurance companies. To get your child started in services, please complete the following form and return to the school office or call Zumbro Valley Health Center’s main office at 507-289-2089 and request intake.School(select one) Elementary School Middle/High School Child's Name* First Last Date of Birth* MM slash DD slash YYYY Social Security # Address Street Address City State / Province / Region ZIP / Postal Code County of Residence Annual Household Income Number of Persons in Household Individuals Under 18 in Household Parent Name or Contact Person* First Last Phone Number of Contact Person*Insurance Carrier & ID Number Cardholder's Name First Last Cardholder's Date of Birth MM slash DD slash YYYY Secondary Insurance Carrier & ID Number (if applicable) Secondary Cardholder's Name First Last Secondary Cardholder's Date of Birth MM slash DD slash YYYY HiddenEmail NameThis field is for validation purposes and should be left unchanged.
