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Home
Who We Are
Services
Locations
Referrals
Resources
Accepted Insurances
Non-Profit
Blog

(843) 793-2104 Client Portal

School Based Mental Health Services

If you are with one of our partnered schools and would like to refer your student, please complete and submit the referral form below

Referral - School Based Services

Person Making Referral

Referrer Email

Phone

School Name

Student First Name

Student Last Name

Grade Level

Date of Birth

Student Primary Email

Name of Parent / Guardian

Relation to Student

Phone Number

Name of Parent / Gaurdian

Relation to Student

Phone Number

Service(s) Requested

Individual Therapy

Family Therapy

Psychological Testing

Psychiatry/Medication Management

RBHS

Challenges & Concerns (Check All That Apply)

Academic Performance (Unsatisfactory grades, coursework challenges)

School Behavior (Disciplinary actions, removal from school)

Behavior (Frustration, hostility, rebelliousness)

Sleep (Sleep disturbances, fatigue)

Anxiety (Excessive worry, somatic complaints, avoidance)

Delinquent Behavior (Theft, legal troubles)

Trauma (Emotional distress)

Self-Harm Behavior (Harmful actions towards oneself)

Grief/Loss (Mourning, bereavement)

Drug/Alcohol Use (Substance use, dependence)

Social concerns (getting bullied, poor social skills)

Attention Problems (distracted, poor concentration)

Depression (loss of interest, irritability, social withdrawal)

Homicidal Ideation (thoughts of hurting/killing others)

Suicidal Ideation (Considerations of self-harm, including any plans or past experiences.

Message

Insurance Provider

Policy / Medicaid Number

Privacy & HIPAA Acknowledgement:

By submitting this referral form, you are formally acknowledging that the information provided herein is, to the best of your knowledge, entirely accurate and provided with consent from the patient. You acknowledge that the information provided here is for referral purposes only, and no other Protected Health Information (PHI) is to be shared between you as the referring provider and Trusted Results Therapy Group, LLC, without proper written authorization from the patient. Trusted Results Therapy Group strictly adheres to all applicable rules and regulations governing PHI, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

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See our Partnered Schools

We’re proud to be an in-school therapy provider for several different schools. These include:

Daniel Island School

Philip Simmons Elementary School

Philip Simmons Middle

Howe Hall Aims Elementary School

Sangaree Elementary School

Berkeley County Middle College

If you have any questions about our student therapy services, don’t hesitate to reach out to us today for more information.

Professional Support For These Challenges and More

GRIEF / LOSS

ANXIETY

ANGER

RELATIONSHIPS

TRUAMA / PTSD

ADHD

DEPRESSION

And More...

Register Now

(843) 793-2104

Privacy Policy

Locations

Charleston

2000 Sam Rittenberg Blvd, Suite 2011

Charleston, SC 29407

North Charleston

3520 W Montague Ave, Suite 201

North Charleston, SC 29418

Myrtle Beach

2102 Cromley Circle, Unit A

Myrtle Beach, SC 29577

Rock Hill

454 S Anderson Rd, Suite 210

Rock Hill, SC 29730

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