School Wellness Program To learn more, fill out the below form: Child's Name Child's Date of Birth Child's Grade and School Guardian's Name Guardian's Phone Number Have you noticed any of the following in your child? Sadness Nervousness Worriedness Distractedness Other If other, please describe: Have there been any major changes in your child’s life recently? Do you think it would be helpful for your child to see a mental health therapist? Additional Comments Send
