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Parent/Guardian Mental Health Referral Form
Referral form for Parent(s)/Guardian(s) to request meeting for child with the mental health specialist.
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Email
*
Your email
I am requesting that a mental health specialist speak with my child:
URGENT-today!
As soon as possible
After the counselor/mental health specialist and I talk
Student's Name
Your answer
Your Name
Your answer
Relationship to student
Your answer
Phone #
Your answer
Best times to reach me
Your answer
My primary concern(s) (Check all that apply)
Something's wrong but I don't know what
A loss (e.g. death of person/friend/pet; divorce)
Perfectionism
Relationships with friends/peers
Relationships with adults (parents/teachers)
Relationships with family
How my child is treated by others
Feelings of negativity, discouragement, self-doubt
Unhealthy or unsafe choices
Other:
Additional information regarding concern(s)
Your answer
Send me a copy of my responses.
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