Mental Health Services And Support Referral Form printable pdf download

Mental Health Services And Support Referral Form

Mental Health Services and Support

Referral Form

The purpose of this referral form is to allow school staff to refer students who may be experiencing

distress related to mental health issues (i.e. depression, anxiety, lack of control, etc.). Completion of this

form will initiate contact between the Mental Health Specialist and the student. As we are bound by

Michigan laws regarding access to mental health services and HIPAA regulations regarding privacy and

confidentiality, the referring source will only be notified that contact was made or attempted –

information regarding treatment will not be shared without a signed disclosure form.

Student’s Name: ________________________________

D.O.B.: ___________

Grade: _____________

Parent Name: ________________________ Date Contacted: ______________

Phone: __________

Please check any of the following concerns you have regarding the student:

Verbally abuse

Frequent suspensions

Change in school performance

Lacks concentration and motivation

Aggressive

Appears depressed

Suicidal talk

Self mutilates

Known stress at home

Relationship issues

Peer concern

Parental concern

Other: ____________________________________________

Please identify one or more strengths this student has:

Wants to improve

Accepts responsibility

Resourceful

Organized

Has friends

Accepts others

Able to problem solve

Other: ___________________________________________

Person Referring: ___________________________ Room #: ________ Date Completed: ___________

mhpreferralformrevised

Mental Health Services And Support Referral Form