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School Based Mental Health Counseling Referral Form

School Based Mental Health Counseling Referral Form

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"*" indicates required fields

Referrals for school-based mental health counseling services at our partner schools may be submitted by school staff/faculty, parents/caregivers, primary care physicians, or other individuals connected with the referred student’s care. Submission of the referral form constitutes understanding and agreement that the referral will be communicated to the student’s school.
Student's Legal Name*
Date of Birth*
Preferred Student Name*
If over 18
Primary Address*
Parent/Guardian Name*
Parent/guardian’s relationship to child:*

Parent/Guardian’s preferred mode of contact*
If the student is being cared for by anyone other than a biological or adoptive parent, a court order for legal custody/guardianship must be reviewed and approved by Samaritan before services can be rendered. Please send a copy of the court order with the referral, if possible. If you have any questions or concerns regarding a student’s situation, please call (920) 886-9319.
Is an interpreter needed for parent appointments and scheduling?*
Is an interpreter needed for student appointments?*
Person Submitting Referral*
Referring individual’s relationship to child:

Has the student attempted suicide or been hospitalized for acute crisis of self-harm 2+ times in the past 12 months?*
Has the referred student received school-based counseling services through Thrive/Samaritan before?*
Please review the following information with the parent/guardian prior to submitting the referral and indicate where appropriate:
This field is for validation purposes and should be left unchanged.