Mental Health Support School Permission Form
Please complete this form to request and authorize school-based mental health support coordination for a student.
Student Information
Student Full Name
*
First Name
Last Name
Grade Level
*
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
School Name
*
Parent or Guardian Details
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Student
*
Please Select
Mother
Father
Legal Guardian
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Support Request Details
Reason for Requesting Support
*
Preferred Type of Support
*
Please Select
Counseling Check-In
Coping Support
Academic Stress Support
Behavior Support
Other School-Based Support
Preferred Contact or Meeting Time
Hour Minutes
AM
PM
AM/PM Option
Communication and Permission
Acknowledgement
Permission to discuss support needs with school staff
*
I agree
I do not agree
Emergency Contact and Signature
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent or Guardian Signature
*
Date of Authorization
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Form
Submit Form
Should be Empty: