School (SIPS) Referral

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COVID-19 Information

SIPS (Student Intervention Prevention Services) Referral Form

Schools partnered with CMET, please complete the following information for the student you are referring for services. Our therapist will be reaching out the family to schedule services.

School who are currently not partnered with CMET, please reach out to our CEO, Patrick Chalmers, at

954-835-5741, we would love to establish and partnership to help children succeed.

Referring School

Reference Contact Name

Parent/ Guardian Name

Reference Contact Phone

Parent/ Guardian Phone Number

Child's First Name

Child's DOB

Child's Last Name

Child's SSN

Child's Medicaid Insurance Card Number (10 digits)

Emergency Contact

Emergency Contact Phone Number

Has the parent been contacted?

Reason for Referral/ Presenting Problem:

Counseling Services Needed

Anger

Anxiety

Depression

Family Issues

Fighting

Grief

Impulse Control

Low Grades

Suspension

Substance Abuse

Truancy

Trauma

Non-Discrimination Policy

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SIPS (Student Intervention Prevention Services) Referral Form

Schools partnered with CMET, please complete the following information for the student you are referring for services. Our therapist will be reaching out the family to schedule services.

​

School who are currently not partnered with CMET, please reach out to our CEO, Patrick Chalmers, at

954-835-5741, we would love to establish and partnership to help children succeed.

​