Please Select the Student's School*Kingsland Public SchoolsPine Island Public SchoolsRochester Alternative Learning CenterDemographic/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 SchoolMiddle/High SchoolChild's Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Social Security #Address Street Address City State / Province / Region ZIP / Postal Code County of ResidenceAnnual Household IncomeNumber of Persons in HouseholdIndividuals Under 18 in HouseholdParent Name or Contact Person* First Last Phone Number of Contact Person*Insurance Carrier & ID NumberCardholder's Name First Last Cardholder's Date of Birth Date Format: MM slash DD slash YYYY Secondary Insurance Carrier & ID Number (if applicable)Secondary Cardholder's Name First Last Secondary Cardholder's Date of Birth Date Format: MM slash DD slash YYYY Email EmailThis field is for validation purposes and should be left unchanged.
