For Clients & Families: Forms

School Based Mental Health Therapy Referral Form

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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.

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

Relationship to child

^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.
Max. file size: 50 MB.

Interpreter needed for parent appointments & scheduling
Interpreter needed for student appointments

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:
Max. file size: 50 MB.
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