Ethridge Elementary 24-25 School-Based Therapy Referral Form
By completing this form you will notify your school's counselor and School-Based Therapist to refer an LCSS student.  This form is confidential and only shared with the school counselor and therapist to initiate the referral process.  Please note that if the student is already seeing a mental health provider, a referral to the School-Based Therapist may not be made, but they will reach out and make that appropriate decision with the legal guardian. Thank you for caring for our student's well being!
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Email *
Student Name *
What grade is the student in?
Clear selection
Reason for making a referral *
Parent Guardian Name/Phone Number
Name of Person making this referral *
Phone number of person making this referral *
Email of person making referral
Is this the student's first time to see at therapist?
Clear selection
Does the student/student's family have DCS involvement (i.e., Juvenile Justice, CPS investigation)?
Clear selection
Is the student in foster care (state/DCS custody)?
Clear selection
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