2023-2024 Milton School-based Referral Form

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By filling out this form, the parent/guardian is requesting counseling services by Stateline Mental Health Services. Once this form is submitted, someone from Stateline Mental Health Services will contact the parent/guardian to obtain further information and a session will then be scheduled.

Name of the student being referred. *

Student's date of birth *

YYYY

Student's Gender *

Female

Male

Prefer not to say

Student's Grade *

Student's School *

Parent/Guardian's name *

Parent/Guardian's phone number *

Parent/Guardian's email *

Can a voice message be left by someone from Stateline Mental Health Services *

Yes

Which is the preferred way to complete new client paperwork? *

online

pen/paper

If person filling out this form is NOT the parent/guardian, provide your name, title, and telephone number.

Please review the following Liability Waiver and acknowledge below.

Yes, I agree to the conditions stated above and give my permission to receive mental health services through Mercy Options or Stateline Mental Health at Milton Schools during school time. This shall remain in effect until therapy services are ended or I provide a written statement to revoke my permission for such services.

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