Samaritan Counseling Center | DEMO – New School Based Mental Health Therapy Referral Form

I understand that Samaritan Counseling Center cannot release any medical or scheduling information without a valid release of information signed by the student’s parent/legal guardian.

Parent/legal guardian is aware that services are for mental health therapy which will be provided through video telehealth services. The parent/legal guardian is required to attend the first session.

Parent/legal guardian has been made aware that the program will bill the child’s insurance carrier for the therapy services provided.

This family has financial barriers and may require financial assistance.

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DEMO – New School Based Mental Health Therapy Referral Form

DEMO – New School Based Mental Health Therapy Referral Form

School

Student Details

Parent Details

Referral Details

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DEMO – New School Based Mental Health Therapy Referral Form

DEMO – New School Based Mental Health Therapy Referral Form

School

Student Details

Parent Details

Referral Details