Consent for Referral to School-Based Mental Health Services

Dear Parents/Guardians:

Per our conversation, as part of the Rockdale County Public Schools student support program, your child has the opportunity to work directly with licensed, school-based therapists who are trained to assist your child with his or her behavioral and social/emotional needs through individual and/or group sessions. These services are designed to help your child achieve success in school.

School-Based Mental Health Services (SBMH): School-Based Mental Health (SBMH) services are those services (individual, group, and/or family counseling/consultation) that are provided by a licensed, therapist in a school setting contracted by Rockdale County Public Schools (Academy for Family Empowerment - AFE). Students dealing with social/emotional issues may be referred for this service. (Social/emotional issues may include, but not be limited to: trauma, loss, adjustment, unusual changes in mood, discipline issues, thoughts of suicide, and/or self-harm.) Once your child is referred for SBMH services, someone from AFE will contact you.

We look forward to working with your child and creating a positive and rewarding experience for everyone.

Student Name: *

Student ID:

School: *

Phone Number: *

Grade: *

Sex: *

Male

Female

Other:

DOB: *

YYYY

Age: *

Referral Date: *

YYYY

Parent/Guardian Consent for Referral to School-Based Mental Health Services *

I give permission for my child to be referred to Academy for Family Empowerment to receive School-Based Mental Health Services in Rockdale County Public Schools. Further, I understand that as part of the referral process, RCPS will disclose to AFE my child’s health/education information including the results of the Behavioral Health Screening.

I do not give permission for my child to be referred to receive School-Based Mental Health Services in Rockdale County Public Schools.

Required

I verify that I am, in fact, the current legal guardian for the above-named child. (Full Name) *

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