Request edit access
Mental Health Counseling Referral Form
Please fill out the information and submit the form and it will automatically be sent to JaiMeer Goodman, RMS Mental Health Counselor.
Sign in to Google to save your progress. Learn more
Email *
Todays Date *
MM
/
DD
/
YYYY
Student Name *
Student Grade Level *
0 points
Name of the person referring student: *
Relationship to the student: *
Parent / Guardian Contact Information: *
Please briefly summarize the concerns you have about this student in terms of behavior, social skills, family dynamics, trauma history, and/or emotional regulation: *
Has the guardian been contacted regarding School Mental Health Services:
 *
How was the parent contacted? *
When was the parent contacted? *
Is the student currently receiving counseling?
 *
List any other agencies involved with the student? *
To qualify for RBHS services, the student must demonstrate moderate to severe impaired functioning in at least two of the following areas (check all that apply):
 *
Required
Has the guardian been contacted regarding School Mental Health Services:
 *
Is there any other information you need to share? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Greenville County School District.

Does this form look suspicious? Report

Google Forms