KATELYN'S PLACE MENTAL HEALTH INTEREST FORM

CM & Katelyn's Place MENTAL HEALTH INTEREST FORM
Community Montessori is pleased to share a partnership with Katelyn’s Place (Phone: 502-303-4063), located in New Albany, for mental health services for our children and teens. Starting in August 2024, (in addition to our virtual services with Centerstone) children and teens can receive in person therapy sessions on our campus and all insurance providers are accepted.

This is a fantastic opportunity for our learners to get the support they need conveniently and safely - on campus, and IN person! Teen and younger capable learners will walk independently to the Courage Cabin for an IN-PERSON session while some elementary-aged learners may be walked up the hill to the Courage Cabin or meet in the main building.

Fill out this form to start the intake process and get on the schedule before spaces are filled. The intake process will be coordinated by Katelyn’s Place and Community Montessori will provide the space for on campus therapy.

Please contact Aimee Joy or Barbara Burke Fondren with additional questions.
Date*

MonthDayYear
Date
Learner's Name*
Teacher/Studio*
Date of birth*

MonthDayYear
Date
Gender at Birth*
Grade Enrolled*
Address*
City*
State*
Zip Code*
Parent/Guardian Name*
Parent/Guardian Phone*
Parent/Guardian Email:*
example@example.com
Insurance Provider information*
Reason for mental health services (Once you submit, this information will be shared with the school liaisons and Katelyn’s Place.*
Should be Empty:

CM & Katelyn's Place MENTAL HEALTH INTEREST FORM