Consent for Behavioral Health Screening

Student Name:      ______   Student ID:       School:       Grade:               Date:      

Dear Parents/Guardians:

Rockdale County Public Schools wants all of our students to be successful in school.  Toward that goal, we have in place a student support program that provides a variety of individual and/or group services to help students with issues that may be impacting their success.  

The first step in connecting your child with the appropriate services is a brief Behavioral Health Screening.  The Behavioral Health Screening, conducted by an RCPS Prevention and Intervention Specialist (P&I Specialist), helps determine what needs your child might have.  Based on the results of the screening, the P&I Specialist, other support staff, and you will decide how to link him or her to resources that can help with addressing those needs.  The P&I Specialist will review the results with you once the screening has been completed.  The P&I Specialist assigned to your school 
____________________________________
(Name/Phone/E-mail)

Reason for Behavioral Health Screening.  (Check all that apply)
 Sudden behavior changes	 Unruly, disruptive behavior	 Emotional issues	
 Drug/alcohol use	 Family or life changes	 Discipline referrals	
 Academic problems	 Truancy	 Other	
 Transitioning from another placement or school	

Parent/Guardian comments:
     

________________________________________________________________________________________________________
Parent/Guardian Consent for Screening
____     I give my permission to the Rockdale County Public Schools to administer a Behavioral Health Screening* to my child.	
____     I do not give permission to the Rockdale County Public Schools to administer a Behavioral Health Screening* to my child.	

Parent/Guardian Signature
By my signature below, I verify that I am, in fact, the current legal guardian for the above-named child.

Parent/Guardian signature_____________________________________________    Date: ________________________________	

If you have any questions or concerns, please contact: __________________________________________  (Name/Phone/E-mail)

Return completed form to contact listed above.