Mind Harbor Intake Form CRANDALL HIGH SCHOOL
LPC SUPPORT ELIGIBILITY RUBRIC
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Crandall High School offers brief, solution-focused, school-based counseling (up to 8 sessions ) for students with mild-to-moderate needs. Before initiating a referral, Alpha Counselors must verify student eligibility using this screening rubric.
Screening Criteria
Tier 1 Support
Alpha Counselor Managed
Academic struggles (missing work, study habits, GPA stress)
Minor peer misunderstandings & social friction
Mild, routine family conflicts or sibling friction
Standard testing anxiety or schedule adjustments
Isolated emotional outbursts or minor disruptions
PROTOCOL & ACTION:
Maintain primary in-house counselor support. Standard check-ins and academic adjustments apply.
Mild-to-Moderate
LPC Eligible Requires ongoing symptoms where standard Alpha check-ins are insufficient
Ongoing anxiety over post-secondary plans or academic failure
Ongoing grief, family separation, or relocation adjustments
Chronic self-doubt, persistent social anxiety, or stress
Persistent relational boundary issues or social withdrawal
PROTOCOL & ACTION:
Initiate Tier 1 strategies. If symptoms remain ongoing, complete Page 2 electronically to refer to the LPC.
Severe / Intensive
Outside Referral Required
Severe clinical trauma, physical or emotional abuse
Substance abuse, vape/nicotine addiction, or eating disorders
Complex custody crises, severe family/home instability
Acute psychiatric episodes or immediate safety risks
PROTOCOL & ACTION:
Provide immediate crisis protocols. Coordinate long-term external care with community partners.
Counselor Referral Decision Workflow
1. Alpha Support Assess initial concerns
2. Provide Tier 1 Support Implement on-campus strategies
3. Confirm Eligibility Verify against LPC rubric
4. Submit Referral Complete Page 2 electronically
LPC Support Referral Form
Submit this secure form to the Licensed Professional Counselor (LPC) for short-term counseling review.
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* Indicates required question
Student Information *
Student Name
__________________
Student ID
__________________
Grade
__________________
Referring Counselor
__________________
Referral Date
__________________
Primary Concern *
Anxiety & Worry
Social Skills & Peers
Grief & Adjustment
Family/Home Change
Other: ____________
Required Interventions Attempted * (2 minimum)
1:1 Alpha Counseling
Impact: _____________________________________________
Parent Consultation
Date & response: _____________________________________
Teacher Consultation
Key feedback: _______________________________________
Academic Modifications
Accommodations: ____________________________________
1. Referral Concerns & Impact on Student Functioning * Describe ongoing symptoms, frequency, and impact on academic or social functioning.
2. Proposed Solution-Focused Goal * What target skill or positive behavior shift will this brief counseling model address?
LPC Program Review File (Admin Use Only)
Intake Decision
APPROVED: Solution-Focused (6 to 8 Sessions)
DIVERTED: Return to Alpha (Enhance Tier 1)
REFERRED: External Community Clinical Partners
LPC Reviewer Signature
_________________________
Date
_________
Lead Counselor Signature
_________________________
Date
_________
Mind Harbor Family Guide Family Information Guide
WELCOMING YOU TO LPC SERVICES
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Our School Counseling Pathway
Welcome! Our school-based short-term counseling program is a brief, supportive initiative designed to help students overcome mild-to-moderate emotional hurdles, build positive coping skills, and return to their classroom ready to learn, play, and connect.
What is Solution-Focused Support?
School-based brief therapy is not about uncovering deep-seated historical trauma. Instead, it is highly structured, present-focused, and centered on identifying your student's unique inner strengths and building practical coping mechanisms.
Goal-Directed Focusing on one key skill or shift to support behavioral or emotional growth.
Strengths-Based Utilizing techniques your student already excels at to resolve hurdles.
Your On-Campus Team
To wrap comprehensive care around your student, two specialized professionals collaborate continuously throughout this process:
α
Alpha Counselor Coordinates everyday school support, academic guidance, and Tier 1 classroom checks.
L
Licensed Professional Counselor (LPC) Provides clinical short-term therapy within the dedicated 6 to 8-session brief model.
Understanding Types of Support
Brief Short-Term Counseling
Strictly limited to 6-8 school-day sessions
Targets situational barriers to class learning
Structured skills and emotional checkups
Fully integrated with on-campus support
Long-Term / Clinical Therapy
Open-ended, ongoing sessions
Explores deep trauma or severe pathology
Requires clinical diagnostic testing / DSM-5
Conducted off-campus (private clinics)
The Path Forward
THE COUNSELING JOURNEY
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PHASE 1
Sailing Safe
Sessions 1 - 2
Building therapeutic safety. The LPC and student identify individual strengths and formulate a single achievable coping goal.
Goal setting & Trust
PHASE 2
Steady Navigation
Sessions 3 - 5
Deep dive into practical strategies: stress regulation, cognitive tools, and peer communication drills.
Skill Practice & Drills
PHASE 3
Entering Harbor
Sessions 6 - 8
Consolidating coping strategies, reviewing growth data, and formulating a long-term transition plan for the student.
LPC Consent Form CRANDALL HIGH SCHOOL
LPC SERVICES CONSENT FORM
CONSENT FILE
Crandall High School offers short-term, solution-focused, school-based counseling services (typically 6 to 8 sessions ) to support student academic and emotional success. To initiate these services, please complete this form.
Student & Family Information
Student Name
______________________
Student ID
______________________
Grade
______________________
Parent/Guardian Name
______________________
Contact Phone
______________________
Email Address
______________________
Brief Counseling Model
Short-term counseling at Crandall High School focuses on practical behavioral strategies, stress management, relational boundaries, and emotional self-regulation. These sessions are scheduled collaboratively with teachers to minimize core academic disruptions.
Confidentiality Notice
Sessions are completely private to build trust. Specific details stay between the student and LPC. However, we must share info if a student is: (1) hurting themselves, (2) intending to hurt others, or (3) being hurt by someone else.
Outside Mental Health Support & Release of Information
To ensure continuity of care and prevent therapeutic overlap, please indicate if your student is currently receiving services from an outside counselor or therapist:
No, they do not see an outside counselor.
Yes, they currently see an outside counselor.
Consent for Release of Information (ROI) Authorization:
If "Yes" is checked above, I authorize the Crandall High School LPC to communicate with the provider listed below to coordinate care and share relevant diagnostic or school support strategies:
Provider / Counselor Name
______________________
Clinic / Organization
______________________
Phone / Email Contact
______________________
Parent/Guardian Consent Statement & Authorization
I have read this consent form, understand the short-term brief solution-focused model (6 to 8 sessions), and have reviewed the Confidentiality Notice. By signing below, I grant permission for my student to participate in short-term LPC counseling services at Crandall High School.
Parent/Guardian Printed Name
____________________________________________________
Date
_____ / _____ / 2026
Parent/Guardian Signature
