School Based Mental Health Therapy Referral Form "*" indicates required fields 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 Date of Birth* Sex assigned at birth* This allows Catalpa health to accurately connect care with the child’s existing medical record.Student's Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Parent/Legal Guardian Name Parent/Legal Guardian's Phone NumberParent/Legal Guardian's Email Address Relationship to child Biological/adoptive parent Step-parent^ Grandparent^ Foster parent^ Court Appointed Legal Guardian^ Other ^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. We know that step-parents, grandparents, foster parents and other family members play an important role in a child’s life, however, these individuals are not able to legally consent to mental health services in the state of Wisconsin. 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 hereMax. file size: 50 MB.Interpreter needed for parent appointments & scheduling No Yes Interpreter needed for student appointments No Yes Parent's Primary Language School Student's Grade Referring 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:select oneTherapy onlyPsychiatry onlyBoth therapy & psychiatryPlease check all past and present concerns that you are aware of:* ADHD Alcohol or drug abuse Anxiety Autism Spectrum Disorder Behavioral concerns at home Behavioral concerns at school Bereavement Chronic suicidal ideation & self-harm Past suicide attempt Depression Eating disorder Gender identity/exploration Homelessness Mood management Obsessive compulsive disorder Psychosis Selective mutism Significant family discord Significant trauma Social/peer relationships Tics/Tourettes syndrome Truancy 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?*select oneUnsureYesNo 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.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 hereMax. 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. Please check this box if the family has financial barriers that may require financial assistance (e.g. high deductible commercial insurance plans, no insurance coverage, ineligible for Medicaid/BadgerCare). HiddenHIPAA Forms Plugin Email Δ