SCREENING & REFERRAL FORM

ELEMENTARY SCHOOL AGES 4-12

CONFIDENTIAL

Please complete this form and our team will strive to make a connection with parents within the first 24-48 hours.

Referrer has:
Immediate Referral to 911/MRT/Psychiatric Care/Emergency Room

South County MERT can be reached at 1-800-952-2235

Referral to PVPSA

Other Information About The Student

Does the student have Medi-Cal?

Directions: After submitting the form, if the student possesses any symptom the students shall be referred to PVPSA for a complete assessment. Your assistance in describing the symptoms or observations will aid in the assessment process.

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