Supporting Students’ Mental
Health and Wellbeing
SSMH3 - Request for Information from Clinical Care Provider
Instructions for template use
The following template is for use when contacting a clinical care provider (e.g. general practitioner, psychiatrist or allied
health professional) seeking information and advice regarding educational adjustments and relevant information about a
student’s mental health difficulty to support the student.
Having copied the text of this letter onto school letterhead, please attach Form SSMH1 Parent/Carer/Student Consent for
the clinical care provider’s information.
Template
[Insert school letterhead here]
Date
[Insert Name of Clinical Care Provider]
[Insert address details of Clinical Care Provider]
Dear Name
Re: [Student’s full name, date of birth, year level, school]
I have been advised by [Insert name of student or parent] that [Insert student’s first name] has been working with you.
We are seeking any information or advice that would assist school in developing a Student Plan that describes the
educational adjustments that may need to be made by the school to assist [Insert student’s first name]’s education. Your
assistance in providing this advice and any relevant documentation relating to the nature and likely impact of the student’s
mental health status that would be relevant would be appreciated.
A copy of the signed Parent/Carer/Student Consent Form providing consent for release of this information is attached.
Please contact me if I can be of further assistance.
Yours sincerely
[Signature]
[Case Manager ]
[Signature]
[Principal]
Suggested/ possible enclosures:
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


Form SSMH1 Parent/Carer/Student Consent
Information about educational progress
Additional information
Stamped, addressed envelope
Uncontrolled copy. Refer to the Department of Education andTraining
Policy and Procedure Register at http://ppr.det.qld.gov.au to ensure you have the most current version of this document.
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