School Mental Health Clearance Form
Share school coordination details and clearance status. Please do not include clinical details.
Student name
*
First Name
Last Name
School
*
Grade
*
Please Select
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
Homeroom or class
Parent or guardian name
*
First Name
Last Name
Parent or guardian email
*
example@example.com
Parent or guardian phone
Please enter a valid phone number.
Format: (000) 000-0000.
Clearance status
*
Cleared to return
Follow-up needed before return
Status not yet determined
Clearance effective date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School contact for coordination
*
Submit
Should be Empty: