School Based Mental Health Therapy Referral Form

Please note, this referral form should only be used by school staff to refer students enrolled in schools that participate in the E3, 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*

Preferred name

Date of Birth*

Sex assigned at birth*

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

Address

Street Address Address Line 2 City State ZIP Code

Parent/legal guardian name

Phone

Relationship to child

Biological/adoptive parent
Step-parent^
Grandparent^
Foster parent^

^If the student is being cared for by anyone but a biological or adoptive parent, a court order for legal custody/guardianship must be reviewed and approved by Catalpa before services can be rendered. Please send a copy of the court order with the referral, if possible. If there are questions regarding a student’s situation, please call 920-750-7088 to discuss.

Upload a PDF of the court order for guardianship here

Max. file size: 50 MB.

Interpreter needed for parent appointments & scheduling

No
Yes

Interpreter needed for student appointments

No
Yes

Parent Primary Language

School

Grade

Referring staff's name

Direct Phone and Extension

Email

Specific 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 may be submitted for when the student has stabilized.

Please review the following information with the parent/legal guardian prior to submitting a referral:

Your school district’s release of information, for purposes of referral to Catalpa Health, is signed and properly dated by the child’s biological/adoptive parent or court ordered legal guardian. (Releases signed by a step-parent, grandparent, other relative or friend will not be accepted without the individual being identified as a legal guardian by court order.) If the parent/legal guardian declines to sign a release, the release is not included, or is deemed invalid, Catalpa will be unable to communicate information regarding scheduling and appointment status with the school. The referral will still be accepted.

Upload a PDF of the release here

Max. file size: 50 MB.

Parent/legal guardian is aware that services are for mental health therapy and that the parent/legal guardian is required to attend the first session.
Parent/legal guardian has been made aware that the program will bill the child’s insurance carrier for the therapy services provided.
Parent/legal guardian and student have been made aware that masks are required for in person therapy appointments, regardless of vaccination status.
Please check this box if the family has financial barriers and may require financial assistance.

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School Based Mental Health Therapy Referral Form

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