School Based Mental Health Counseling Referral Form

The referred family has been made aware that the referral is for school-based mental health counseling services provided by licensed clinical mental health clinicians or qualified treatment trainees through Samaritan Counseling Center, has been made aware that referral documentation will be forwarded by Samaritan to the school for which the referral has been made, and has given their consent to this communication/release of referral information.

The parent/guardian has been made aware that Samaritan requires treatment consent from BOTH custodial parents in cases of joint custody.

The referred family has been made aware that participation in school-based counseling requires the release of the following information to the school: enrollment status, appointment times, and if/when the student has been discharged.

The parent/legal guardian has been made aware that they are required to attend the first session and may be asked to participate in future sessions based on treatment recommendations of the clinician.

The parent/legal guardian has been made aware that the program will bill the child’s insurance carrier for the therapy services provided. If the provider at your school site is not covered by the family’s insurance, funding may be provided to cover fees.

This family may require financial assistance.

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School Based Mental Health Counseling Referral Form

School Based Mental Health Counseling Referral Form

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School Based Mental Health Counseling Referral Form

School Based Mental Health Counseling Referral Form

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