2023-2024 EISD Student and Family Mental Wellness Referral Form    
We are on a waitlist for general counseling for on-campus and adult services. If you made a referral, please inform the legal guardian they will be contacted as soon as there are openings. We do have services with Clarity at Emma and with Rise Recovery services.
  • Services are available ONLY for EISD students and their Legal Guardians. 
  • Each person will need their own referral. 
  • EISD student referrals should ONLY be submitted AFTER securing a signed consent. 
  • By completing this referral form, you are certifying that you already have the signed consent form for this student. 

If a mental health emergency, don't hesitate to contact the Mobile Crisis Outreach Team (MCOT) through the 24-Hour Crisis & Substance Use Helpline: 800-316-9241 or 210-223-SAFE (7233). You may also call 911 or go to your nearest emergency room. 

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Email *
Name of Person Completing Referral Form: *
Role of Person Completing Referral Form *
Please select one  *
Referral's Last Name *
Referral's First Name *
Referral's Date of Birth *
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Referral's Age *
Referral's Gender
 *

Referral's Ethnicity

 *
Referral's Race
 *
If a minor, was Consent Received by Parent/Guardian?

** EISD student referrals should ONLY be submitted with securing a signed consent. 
 *
Required
Consent Received on Date:
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Student ID (if an adult or youth does not attend EISD, enter 0000 ) *
Referral's Campus Name 
(If services are for a family member, select the student's campus.) 
 *
Referral's Grade Level *
Referral's Address *
Zip Code *
Please select your Household Size *
Please select your household income *
If a minor, please provide Parent/Guardian Name *
Phone Number (If a minor, please provide Parent/Guardian Phone Number)  Due to the high demand for our services, your referral will be closed if we do not hear from you after our 3rd contact attempt. Please be sure voicemails are set up so our staff can leave messages.   *
Email Address (If a minor, please provide Parent/Guardian Email)
 *
Referral's Preferred Language  *
If a minor, Parent/Guardian Preferred Language *
Primary Reason for seeking services:   *
Check other related reasons for requesting services: *
Required
Please describe checked boxes in detail (frequency, duration, first-time occurrence) or provide any additional information for the therapist. 


Preferred Service
 *
If "on-campus" services are requested, note the days and times the student can be seen. 

Please provide the name and phone number of the campus's point of contact to reserve a room for the sessions. 

Are you or anyone in your household currently active duty, reserve, or veteran? If so, please list the status and relationship? (ex. Veteran/Mother, Reserve/Self)

 

 *
For Student Referrals Only! Academic/Attendance/Behavior Progress Self Report   

Academic Progress- Grades (at time of referral)
 *
Academic Progress- Attendance (at time of referral) *
Academic Progress- Behavior (at time of referral) *
How did you hear about our program?  *
To learn more about our partners, visit us at www.mentalwellnesscollaborative.org  

A copy of your responses will be emailed to the address you provided.
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