Mental Health Provider Report

To Parents: Please proceed with this form IF YOUR CHILD has received professional counseling from a psychiatrist, psychologist, therapist, counselor, or family doctor within the last year. Please share this form with the mental health provider to fill out. If your child is not receiving any mental health services, you DO NOT NEED to submit this form.


To the Mental Health Provider:
The admissions Committee at Solebury School requires information from a mental health provider when a prospective student has been receiving professional counseling. The questionnaire will help up evaluate the student's readiness for Solebury School. We would encourage you to read the description of Solebury, by visiting our website in order to gain a more complete perspective of our community. Please do not hesitate to call us if you would like to discuss the student's placement. Thank you for responding to our questions. The information provided will remain confidential.

4) Has there been a history of depression requiring treatment?required
5) Has the student demonstrated a willingness to engage productively in the therapeutic process? required
6) Has this student shown any suicidal tendencies and/or self-injurious behavior?required
7) Is the student a danger to himself/herself or other?required
8) Does this student have a tendancy to use drugs, or alcohol, especially when under stress?required
9) Has this student had peer problems, or problems dealing with authority figures?required
10) Has this student experienced anxiety that has interfered with their daily activities?required
11) Has this student been caught stealing?required
12) Has there been a history of acting out behavior?required
First Name
Last Name
Must contain a date in M/D/YYYY format