Mental Health Services Request

Mental Health Services Request

Completed by school staff, parent, medical provider
Rock Hill Schools offers several options for site-based mental health services for students. Please complete this form to request a mental health counseling referral for a student. School Counselors will handle all requests and make a referral to the mental health provider that will best meet the needs of the student.
Student Name

First NameLast Name
School
Grade
Private InsuranceMedicaidNo InsuranceUnknown
Name of Medicaid Plan (if known)
YesNoUnknown
Please give a brief reason for request. Details can be discussed at intake. If this is mental health emergency, please take your child to the emergency room.
Name of person requesting referral
Name
Relation to Student
Email of person requesting referral
example@example.com
Phone Number of person requesting referral
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: