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RGS School Mental Health Referral
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Student's Name
*
Your answer
Student's DOB
*
MM
/
DD
/
YYYY
Student's Grade
*
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Name of Parent(s) or Guardian(s)
*
Your answer
Primary Phone Number
*
Your answer
Alternative Phone Number
Your answer
Why do you feel this student needs mental health services?
*
Your answer
Risk Assessment. Please select any/all that apply.
Passive suicidal ideations (i.e. "I wish I could go to sleep and not wake up", "I wish I just wasn't here anymore."
Active suicidal ideations with some degree of plan/intent/means to harm self.
Recent suicidal gesture/attempt
History of suicidal gesture/attempt
Current self-harming behaviors (i.e. cutting, burning)
History of self-harming behaviors
Violent/Aggressive behavior
Other:
Additional concerns, information, or other factors related to this child.
Your answer
Have you spoken to the parent/guardian about making this referral?
*
Yes (The family is aware that Jessie will be reaching out with more information)
No
Other:
Insurance information
Medicaid (School Mental Health is covered in full by Medicaid).
Blue Cross Blue Shield
Other private insurance (Aetna, Cigna, United Health, etc.)
Tricare
No insurance
Other:
Clear selection
Parent E-mail Address.
I will send CPT/Billing codes to parents if they have private insurance to verify coverage.
Your answer
Your name (Person who is making this referral)
*
Your answer
Your contact information (name or email)
*
Your answer
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