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: *
DOB: *
MM
/
DD
/
YYYY
Age: *
Referral Date: *
MM
/
DD
/
YYYY
Parent/Guardian Consent for Referral to School-Based Mental Health Services *
Required
I verify that I am, in fact, the current legal guardian for the above-named child. (Full Name) *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy