Jetdoc Mental Health Referral Form

Mental Health Referral
Thank you for entrusting us with the care of your students. This form is designed to streamline the referral process and ensure timely access our mental health services. Please complete the form below with as much detail as possible to help us better understand their needs. Thank you.
Client Information
School*

Cross Keys High SchoolChamblee High SchoolChamblee Middle SchoolDunwoody High SchoolOther
Guardian Name

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Childs Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email Address
example@example.com
Phone Number
Please include area code.
Type of Insurance

MedicaidCommercial Insuranceunisured
Gender*

MaleFemaleNon-BinaryPrefer not to sayOther
Types of services Client is seeking:*

Initial AssessmentIndividual TherapyFamily TherapyPsychiatric EvaluationMedication ManagementCommunity Support ServicesOther
Client is experiencing challenges with:*

DepressionAnxietyADHDLGBTQ+ ConcernGrief or LossPTSD/TraumaAn Eating DisorderAnger ManagementPhobiasA Family Situation or DifficultyOther
Please list current medications:
Anything else we need to know?
Referral Information
Your Name*

First NameLast Name
Title*

Social WorkerSchool CounselorOther
Your Email*
example@example.com
Your Phone Number
Please enter a valid phone number.
Should be Empty:

Mental Health Referral