ALA School-Based Mental Health Referral-Parent
Parental Consent Form
Student's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
Campus
Please Select
SES
SIS
EEE
EEI
SMS
EEM
SHS
ALC
Grade
Parent/Legal Guardian Name
Parent/Legal Guardian Date of Birth
Parent/Legal Guardian Place of Employment (enter n/a if not currently employed)
Please describe why your child is being referred for school-based mental health services.
I, the undersigned, certify that I am the parent/legal guardian of the aforementioned child. I give consent to the Sheridan School District for my child to receive School-based Mental Health Services. I understand that the Sheridan School District has a partnership with an outside provider. I authorize the Sheridan School District to release protected information including but not limited to: school records, demographic information, any behavior/clinical information or other information needed to complete the referral and during treatment of my child in the school-based mental health program to the contracted mental health provider (currently Pinnacle Pointe Outpatient).
Submit
Should be Empty: