School Based Mental Health Referral
Student Name
First Name
Middle Name
Last Name
Student's Gender
Please Select
Male
Female
N/A
Student Medicaid ID or SSN
Insurance Type
*
Medicaid
Private Insurance
Unsure
No insurance
Name of insurance
Insurance ID
Student date of birth
-
Month
-
Day
Year
Date
Parent / Guardian Name
First Name
Last Name
Parent / Guardian Email
example@example.com
Parent / Guardian Cell Number
Please enter a valid phone number.
Has the parent / guardian been informed of this referral
*
Yes
No
Unsure
Referring School Staff Name
First Name
Last Name
Referring School Staff Email
example@example.com
School Name
*
Please Select
LE High
LE Middle
LE Elementary
Wateree Elementary
Doby's Mill
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Reason for visit
These questions will allow us to match you with the most appropriate clinician.
Indicate top reason(s) for this referral (no more than 3)
*
Depression
Anxiety
Traumatic Experience
Career Counseling
Gender identity
Behavioral issues
ADHD Treatment
ADHD Testing
ADHD for School Accommodations
Eating Disorder
Pre- or postnatal mental health symptoms
Autism
Substance use or abuse
Serious mental illness (e.g. hearing voices)
Developmental / learning delay
Check here if the student has experienced thoughts of suicide in the last 6 months
Check here if the student has been hospitalized for mental health concerns in last 6 mos
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