School-Based Referral Form

Please note, this referral form should only be used by school staff to refer students enrolled in schools that participate in the HOST, PATH, and Rise Up School Based Mental Health Programs or the consultation programs at the Community Early Learning Center (including Bridges and Even Start) and UW-Oshkosh Head Start. Referrals for any other service at Catalpa Health should use the Catalpa Health Referral form located at www.catalpahealth.org/referring-providers/. If you have questions about which form to use, please call 920-750-7088 to discuss.

Student Legal First Name*

Student Legal Last Name*

Student Preferred Name

Sex assigned at birth*

This allows Catalpa health to accurately connect care with the child’s existing medical record.

Parent/Legal Guardian Name

Parent/Legal Guardian's Phone Number

Parent/Legal Guardian's Email Address

Upload a PDF of the court order for guardianship here

Max. file size: 512 MB.

Parent's Primary Language

Referral Submitted By (Name)*

Direct Phone and Extension*

Referring Staff's Email*

Name of staff member who knows the student/situation best and can collaborate with therapist*

Oshkosh North & Oshkosh West High Schools Only - Referral is for:

Date of past suicide attempt(s):*

Truancy - how many days has the student been absent in the past 30 days?*

Additional information regarding the reason for referral:*

Student has had thoughts of self-harm and/or suicide in the last 2 weeks?*

If yes, please have a parent or guardian contact the Catalpa Health Call Center Monday-Friday 8:00 a.m.-4:30 p.m. at 920-750-7000 to assess safety risk and schedule as appropriate. Outside of these hours please contact the 24-hour crisis line in the child’s county of residence. A referral to school based programs will be considered when the student has stabilized.

School-Based Referral Form

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