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School-Based Mental Health Referral Form

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School-Based Mental Health Referral Form

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Ver la versión en español del Formulario de referencia de salud mental en la escuela.

Contact our Client Engagement Team at 678-893-5300 if you have any questions regarding school-based mental health services or the referral process.

Student Information
Date
MM slash DD slash YYYY
Age*
Gender*
Ethnicity*
Student's Name*
Birth Date*
MM slash DD slash YYYY
Health Insurance*
- Yes
- No
Insurance Type
Policy Number
Your Name
Email Address
Phone Number
Relationship to Student*
- Parent/Guardian
- Grandparent/Great Grandparent
School Information
School
Grade
Homeroom Teacher
Reasons for Referral
Reasons for Referral*
- Select All
- Academic Performance
- Classroom Conduct
- Behavior (outside of school)
- Trauma
- Suicidal Thoughts and/or Plans - Current
- Suicidal Thoughts and/or Plans - History
- Self-Harm - Current
- Self-Harm - History
- Depression
- Anxiety
- Grief/Loss
- Family/Community Related Concern
- Drug and Alcohol Use
- Health and Wellness Concerns (Please explain in "Additional Comments" section below)
(Check All That Apply)
Referral Source - Who is Requesting Services
Who is Requesting Services
- Student (Self-Request)
- Parent/Guardian
- Teacher
- School Social Workers
- School Counselor
- School Administrator
- DFACS or DJJ
Name
Email
Phone
If referral source is not parent/guardian, can we contact parent/guardian to schedule appointment?
- Yes
- No
Additional Comments about Student Behavior or Symptoms
Additional Comments
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Since 1990, the Summit Counseling Center has brought hope and healing to people in need at every stage of life providing a wide range of specialty services for individuals, couples and families. Summit therapists offer professional counseling integrating body, mind, spirit, and relationships.

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