Helpful Forms

This section shares forms developed by the University of Maryland School Mental Health Program and other affiliated programs.  These forms are available for you to modify to best meet your own program/agency needs.  Permission is granted to use these forms to advance school mental health-related programs and initiatives.  Commercial use of these forms is prohibited.

Forms:

Appointment Log

Confidential Fax Form for Medical Records

Confidential Referral Form

Consent for Release of Information Form 1

Consent for Release of Information Form 2

Discharge Policy Form

Emergency Information Form

Hall Passes (generate your own)

Initial Clinical Assessment Form

Intake and Treatment Form with Tobacco Assessment

Patient's Rights Form

Prescription Record Form

Progress Note

Referral Feedback Form

School Connectedness Checklist

Student Activity Schedule

Suicide Assessment Form

Suicide Safety Agreement (For Elementary/Middle School)

Suicide Safety Contract (For High School)

Supervision Log