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Mental Health and Counseling Services Referral
Please complete this form if you would like to be contacted about mental health and counseling services for your child.
Thank you!
Maddie Tooley
Mental Health Practitioner
madison.tooley@jefferson.kyschools.us
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* Indicates required question
Name of person completing referral:
*
Your answer
Student Name:
*
Your answer
Teachers Name:
*
Your answer
Reason for referral:
*
Social skills
Emotional regualtion
Stress
Depression
Anxiety
Trauma
Life events (divorce, new sibling, death)
Other:
Required
What is the best number to contact you?
*
Your answer
Is there anything else you would like the Mental Health Practitioner to know?
Your answer
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