SCHOOL BASED MENTAL HEALTH REFERRAL FORM - Brighter, Stronger Foundation
Please use this form to make a referral for a student to receive school based mental health services through Brighter, Stronger Foundation. 

If the referred individual is in danger of hurting themselves or others, please call 911 and let them know it is a mental health emergency, go to the nearest emergency room, or call a crisis hotline below:

Anne Arundel County Crisis Response: 410-768-5522
Baltimore City Crisis Response: 410-433-5175
Baltimore County Crisis Response: 410-931-2214
Harford County Crisis Response: 410-874-0711
Howard County Crisis Response: 410-531-6677
Montgomery County Crisis Response: 240-777-4000
Prince George's County Crisis Response: 301-429-2185
The Trevor Project (LGBTQ+): 1-866-488-7386
Email *
Today's Date: *
MM
/
DD
/
YYYY
Does Student Referred Have Any Thoughts/Plans to Harm Self: *
If answered yes, please call 911 and let them know it is a mental health emergency, go to the nearest emergency room, or call the crisis hotline at 988. 
Does Student Referred Have Any Thoughts/Plans to Harm Others: *
If answered yes, please call 911 and let them know it is a mental health emergency, go to the nearest emergency room, or call the crisis hotline at 988. 
Student's Current School: *
Student's Type of Insurance Coverage:
Please note: Therapy and Medication Management services are currently only supported through Medicaid insurance or Self-Pay coverage.
Student's Medical Assistance Number
 *
 If Unknown, Please Enter 0
Student Last Name: *
Student First Name: *
Student Middle Initial: *
Student Date of Birth: *
MM
/
DD
/
YYYY
Student Grade: *
Individual's Gender Assigned at Birth: *
Individual's Current Gender Identity: *
Who is Completing This Referral Form: *
Referral Source Name:  *
Referral Source Phone:  *
Parent/Guardian Name: *
Individual's Primary Language: *
Individual's Ethnicity *
Individual's Racial Category (Check All That Apply): *
Required
Parent/Guardian Address: *
Parent/Guardian City: *
Parent/Guardian State: *
Parent/Guardian Zip: *
Parent/Guardian Phone: *
Parent/Guardian Email
Presenting Problem(s): *
Required
Additional Student Information:
Has the Student's Parent/Guardian Been Notified and Given Consent To This Referral? *
I Certify That I Am Requesting School-Based Mental Health Services For The Above Student And Have Completed This Form Of Request For Services:
 *
A copy of your responses will be emailed to .
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Brighter, Stronger Foundation.

Does this form look suspicious? Report

Google Forms