High School Mental Health Consent & Screening Form
Consent
I give permission for my child to participate in mental health screening and support services at school.
Student Information
Student Name
Date of Birth
Grade
Parent/Guardian Name
Parent/Guardian Phone or Email
Mental Health Screening
How have you been feeling lately?
Have you experienced any of the following recently?
Feeling sad or hopeless
Feeling anxious or worried
Not wanting to be around people
Sleeping problems
Changes in eating habits
None of the above
Is there anything else you want us to know or the kind of support you need?
Student Signature
Date
Parent/Guardian Signature
Date