Please Select the Student's School*Kingsland Public SchoolsPine Island Public SchoolsRochester Alternative Learning CenterZumbro Valley Health Center Kingsland School-Linked Mental Health FormZumbro Valley Health Services will offer mental health care to students at Kingsland School District. Services will include care for a variety of mental health needs, along with the provision of chemical dependency evaluations. Services will be provided in individual, group, and family formats, depending on the student's individual needs. If a student has insurance coverage, a claim may be generated for the service that is provided at Kingsland School District. If a referral is made for more intensive services at Zumbro Valley Health Center offices, the student and parent will be required to do a formal intake with the Customer Service staff to initiate services. In order for your child to receive mental and chemical health care from the Zumbro Valley Health therapist, the following form must be completed and signed. Per MN statute 144.343, a minor may give consent for medical, mental, and other health services to determine the presence of or to treat pregnancy, and conditions associated with venereal disease, and alcohol and other drug abuse.Date* Date Format: MM slash DD slash YYYY Student's Name* First Last GradeTeacherReferral Source*TeacherCounselorStaffParentName* First Last Phone Number*EmailReason for ReferralAnxious/NervousAshamed/GuiltCry Easily/OftenDepressed/SadDistressing MemoriesLose TemperTraumaLow Self-EsteemWorries OftenLossPerfectionSleep ProblemsIrritable/AngryBullies OthersSocial DiscomfortOther comments/concernsZumbro Valley Health Center Pine Island School-Linked Mental Health FormZumbro Valley Health Services will offer mental health care to students at Pine Island School District. Services will include care for a variety of mental health needs, along with the provision of chemical dependency evaluations. Services will be provided in individual, group, and family formats, depending on the student's individual needs. If a student has insurance coverage, a claim may be generated for the service that is provided at Pine Island School District. If a referral is made for more intensive services at Zumbro Valley Health Center offices, the student and parent will be required to do a formal intake with the Customer Service staff to initiate services. In order for your child to receive mental and chemical health care from the Zumbro Valley Health therapist, the following form must be completed and signed. Per MN statute 144.343, a minor may give consent for medical, mental, and other health services to determine the presence of or to treat pregnancy, and conditions associated with venereal disease, and alcohol and other drug abuse.Date* Date Format: MM slash DD slash YYYY Student's Name* First Last GradeTeacherReferral Source*TeacherCounselorStaffParentName* First Last Phone Number*EmailReason for ReferralAnxious/NervousAshamed/GuiltCry Easily/OftenDepressed/SadDistressing MemoriesLose TemperTraumaLow Self-EsteemWorries OftenLossPerfectionSleep ProblemsIrritable/AngryBullies OthersSocial DiscomfortOther comments/concernsZumbro Valley Health Center Rochester Alternative Learning Center School-Linked Mental Health FormZumbro Valley Health Services will offer mental health care to students at Rochester Alternative Learning Center. Services will include care for a variety of mental health needs, along with the provision of chemical dependency evaluations. Services will be provided in individual, group, and family formats, depending on the student's individual needs. If a student has insurance coverage, a claim may be generated for the service that is provided at Rochester Alternative Learning Center. If a referral is made for more intensive services at Zumbro Valley Health Center offices, the student and parent will be required to do a formal intake with the Customer Service staff to initiate services. In order for your child to receive mental and chemical health care from the Zumbro Valley Health therapist, the following form must be completed and signed. Per MN statute 144.343, a minor may give consent for medical, mental, and other health services to determine the presence of or to treat pregnancy, and conditions associated with venereal disease, and alcohol and other drug abuse.Date* Date Format: MM slash DD slash YYYY Student's Name* First Last GradeTeacherReferral Source*TeacherCounselorStaffParentName* First Last Phone Number*EmailReason for ReferralAnxious/NervousAshamed/GuiltCry Easily/OftenDepressed/SadDistressing MemoriesLose TemperTraumaLow Self-EsteemWorries OftenLossPerfectionSleep ProblemsIrritable/AngryBullies OthersSocial DiscomfortOther comments/concernsPhoneThis field is for validation purposes and should be left unchanged.
