Summertown Elementary 24-25 School-Based Therapy Referral
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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Student Name *
What grade is the student in?
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Reason(s) for making referral. *
Parent/Guardian Name and Phone number (if available)
Name of person making this referral *
Phone number of person making referral *
Email of person making referral
Is this the student's first time seeing a therapist?
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Is there DCS involvement in the family (i.e., Juvenile Justice, CPS investigation)?
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Is the student in foster care (state/DCS custody)?
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