School Based Mental Health Therapy Referral Form Student First Name* Student Last Name* Date of Birth Gender Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code School Grade Parent ContactIf the student is being cared for by anyone but a biological or adoptive parent, a court order for legal custoday/guardianship must be reviewed and approved by Catalpa Health 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 us at 920.750.7088 to discuss. PhoneParent Primary Language Interpreter needed for parent appointments & scheduling Yes No Interpreter needed for student appointments Yes No Referring staff's name PhoneReason for referralStudent has had thoughts of self-harm and/or suicide in the last 2 weeks?YesNoUnsure I understand that Catalpa Health cannot release any medical or scheduling information without a valid release of information signed by the student’s parent/legal guardian. Parent/legal guardian is aware that services are for mental health therapy which will be provided through video telehealth services. 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. This family has financial barriers and may require financial assistance. HiddenHIPAA Forms Plugin Email