counselorform - Southwest Prevention

Counselor Form

After submitting this form, you will be given a link to email to the parents for them to complete. If the parent does not complete the form sent to them, they will not be included in the mental health support program. A representative from Southwest Behavioral Health will notify the counselor if the parent has not completed their portion of the form within 10 days.

* Indicates required field

Referring Counselor Name *

First

Last

Counselor Phone Number *

Counselor Email *

Name of Student *

First

Last

Name of Student *

First

Last

Name of Student *

First

Last

Name of Student *

First

Last

Grade *

Grade *

Grade *

Grade *

School *

Name of Parent *

First

Last

Parent/guardian must be notified that the counselor has offered this service. *

I understand, and will notify the parent/guardian prior to submitting this form Once you submit this form, a link will show up on the next page that must be sent to the parent. Please send that link to the parent and ask them to complete it.

Submit

Counties

Organization

Support

Beaver
Garfield
Iron
Kane
Washington

Southwest Prevention is a Division of Southwest Behavioral Health Center

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