School Mental Health Services Referral
Therapist: Jenna Sahli, LPC
Greater Greenville Mental Health Center- Greer Clinic
School Office: 864-355-8473
Greer Mental Health Clinic: 864-879-2111
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Student Name *
Student DOB *
MM
/
DD
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Grade *
Required
Legal Guardian(s) *
Address *
Phone Number (Primary) *
Phone Number (Alternative)
Why do you feel this student needs mental health services? *
Risk Assessment. Please select all that apply. *
Required
Additional concerns, information, or other factors related to this child.
Have you spoken with the guardian(s) regarding your referral? *
Required
Does the family have insurance (*PLEASE NOTE* Our services are not free. Medicaid and Blue Cross Blue Shield are the only insurances considered in-network with SCDMH) *
Individual Making Referral *
Date of Referral *
MM
/
DD
/
YYYY
Relationship to Child *
Contact Information (phone, email) *
Submit
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This form was created inside of Greenville County School District.