Mental Health Encounter Form - School-Based Health Alliance



Fairmont Heights Northwestern Oxon Hill

Wellness Center Wellness Center Wellness Center

1401 Nye Street 7000 Adelphi Rd 6701 Leyte Dr.

Fairmont Hgts, MD 20743 Hyattsville, MD 20782 Oxon Hill, MD 20745

301-925-2870 301-985-1837 301-749-5241

Mental Health Encounter Form

Date of Service: _______________ Name: ___________________________________________ Student ID: ______________________ D.O.B.:___________

Provider: ________________________________________________ Health Ins. Plan: ___________________________________________________ None ___

|Type of Appointment |

| |

| |

| |Mild Mental Retardation |

|Labs | |

|Referral |

| |CRNP/MD |

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