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U-Knighted School Therapist Request for Assistance
Student Mental Health Enrollment/Request for Assistance
Please fill out this form to refer a student to be placed on the School Therapist schedule for the Community Partnership Grant.
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* Indicates required question
Student Name:
*
Your answer
Building:
*
AHGS
AGS
LGS
ALAH HS
Date of Referral:
*
MM
/
DD
/
YYYY
Reason for referral:
*
Your answer
Is this student covered by a Medicaid plan?
Yes
No
Clear selection
Full Address (include City, State and Zip)
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Gender:
Male
Female
Prefer not to say
Clear selection
Parent/Guardian Name:
Your answer
Parent/Guardian Phone:
Your answer
Preferred Method of Contact:
Email
Phone
Best Time for Contact:
Your answer
Student Grade Level:
Choose
PreK
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Does this student receive outside mental health services?
Yes
No
Clear selection
If yes, where at?
Your answer
**Parent/Guardian must provide written consent if the child is <12 years of age. For a child age 12 or older, if parents are unaware/do not consent, sessions are limited to 8 unless student is 18 or older.
Name and Title of referring party:
Your answer
Submit
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