For Printable PDF, click here. Please Select the Student's School* Dover-Eyota Public Schools Kingsland Public Schools Pine Island Public Schools Rochester Public Schools Stewartville Public Schools 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 School(select one) Elementary School Middle School High School School(select one) Alternative Learning Center Longfellow Washington School(select one) Bonner Elementary Bear Cave Intermediate Stewartville Middle Stewartville High School(select one) Elementary School Middle School High School Child's Legal Name* First Last Preferred Name Birth Sex Female Male Gender Identity Female Male Transgender Male Transgender Female Transgender (non-binary) Date of Birth* MM slash DD slash YYYY Grade* Social Security # Address* Street Address City State / Province / Region ZIP / Postal Code County of Residence Parent Name or Contact Person* First Last Relationship to Child* Preferred Language* Phone Number of Contact Person*Address is same as child* Yes No Address Street Address City State / Province / Region ZIP / Postal Code 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 Email* CommentsThis field is for validation purposes and should be left unchanged.
