COUNSELING REFERENCE REQUEST

GEORGE SCHOOL

Because your child has received or is presently undergoing counseling, the George
School Admission Committee requires that your child’s psychologist, psychiatrist or
counselor complete the brief questionnaire that follows and, if necessary, respond to
further inquiries from the George School admission counselor or school counselor. The
responses to the questionnaire will help the Committee make decisions that are in your
child’s best interest and that evaluate their readiness to enter the George School com-
munity. More importantly, this information is critical to providing adequate support for
your child should they be admitted to George School.

Along with the questionnaire you will find an Authorization for Release of Psychological
and Psychiatric Information.

AUTHORIZATION FOR THE RELEASE OF

PSYCHOLOGICAL AND PSYCHIATRIC INFORMATION

I hereby give permission to my child’s counselor to release to George School protected

health information regarding my child, , as requested
on this questionnaire and in follow-up inquiries from the George School admission coun-
selor or school counselor.

The purpose of this disclosure is to help the George School Admission Committee make
decisions that are in my child’s best interest and that evaluate his/her readiness to enter
the George School community. Any disclosed information will also be used by George
School to provide adequate support for my child should they be admitted.

I understand that I may revoke this authorization at any time before it expires by
sending written notice to my child’s counselor, psychologist, or psychiatrist. This
authorization expires at the end of the next academic year. I also understand that the
information disclosed may be subject to re-disclosure by George School.

Parent Name (print)

Parent Signature Date

Child’s name (print)

Child’s signature (if 14 years old or older) Date

PMB 4460 1690 Newtown Langhorne Rd Newtown PA 18940 215.579.6547 FAX: 215.579.6549 admission@georgeschool.org
 GEORGE SCHOOL QUESTIONNAIRE

1. Please give inclusive dates of treatment From August 21st , 2018 to November 11th,
2018
2. What was the presenting issue? He was diagnosed by the psychiatrist Rafael Vasquez
with Obsessive – Compulsive Disorder (OCD). He used to wash his hands every so often,
and buy things compulsively in the past. Jeronimo started the psychological treatment
because he was still feeling some of his OCD symptoms. ____________________________

3. Current issues of concern. (Please include how client’s psychological issues may
impact academic and social functioning. Please also discuss client’s relationship
with parents/parental figures.) He is conscientious and ethical, with strong sense of right
and wrong. He strives to improve things and he is usually afraid of making a mistake. He
tries to maintain high standards and sometimes can become impatient and has low
tolerance to frustration. Jeronimo is able to concentrate and focus on developing complex
ideas and skills. He is usually an easygoing person and has good social skills, even
though he likes to be independent and sometimes claims his own space and tends to
isolate himself. He can be friendly and warm-hearted, specially, when he feels accepted
by others. Jeronimo perceives his parents love him and try to do everything they can to
support his wellbeing. Sometimes it is difficult for him to share his feelings with his father
and tries to avoid conflict with him. Jeronimo considers his father works a lot and does a
lot of things for him, his mother and sister, and he doesn’t like to disappoint him in any
way. The relationship with his mother is closed and he perceives his mother trusts him
and looks after him.

4. Has client ever been hospitalized for a psychiatric condition? No

If yes, please give dates

Any history of self-harm? If so, please describe. Not history of self-harm

5. Are/were psychiatric medications used in treatment? No

If yes, past medications

Current medications
Name of prescribing physician

6. Please summarize your diagnosis and recommendations for ongoing treatment.

Diagnosis: Behavior pattern compatible with obsessional traits and anxiety.
It is recommended to encourage him to do exercise or practice any sport. Foster his
musical skills, and offer him an environment where he perceives himself capable enough
to accomplish his personal and academic goals without pushing him too hard, and where
he feels he is accepted by others, in order to decrease his anxiety levels.

George School PMB 4460 1690 Newtown Langhorne Rd Newtown PA 18940 215.579.6547 FAX: 215.579.6549 admission@georgeschool.org
 Name Juan Camilo Mantilla Phone (+57) 316 339 8653
Address Carrera 18 # 79 – 40 (208), Bogotá D.C. - Colombia

Signature Date 26/12/2018

Thank you for completing this form. Please return this form to George School, Admission Office, PMB 4460,
1690 Newtown Langhorne Rd, Newtown, PA 18940-2414 or send to the confidential fax (215.579.6549).
You may be contacted by the school counselor or admission counselor for further information.

George School PMB 4460 1690 Newtown Langhorne Rd Newtown PA 18940 215.579.6547 FAX: 215.579.6549 admission@georgeschool.org