Student Name (Last Name, First Name):
*
🌸 Mt. Healthy South Referral Form
Complete this form to connect a student with the support, resources, and care they need to succeed academically, socially, and emotionally.
🧾 Who is this Referral For?
*
Please Select
Child/Student
Parent
Family
Teacher/Admin
👤 Referral Submitted By:
*
Please Select
Teacher
School MH Team
Parent/Caregiver
Self
School Admin
✏️ Name of Person Making the Referral (Last, First):
First Name
Last Name
👩🎓 Student Name:
*
First Name
Last Name
🗓️ Student’s Date of Birth:
*
/
Month
/
Day
Year
Date
🎂 Student’s Age:
*
🎓 Grade Level:
*
Please Select
Pre-K (5+ Years)
1st
2nd
3rd
4th
5th
6th
Parent/Guardian Information
All parents/guardians must be called or notified and must provide consent for this referral before it is submitted to Poppy’s Therapeutic Corner.
☎️Has the Parent/Guardian been notified and provided consent for this referral ?
*
Yes
No
Other
Referral Initiated by (Last Name, First Name):
*
Parent/Guardian Name (Last Name, First Name):
*
👨👩👧 Parent/Guardian Name (Last Name, First Name):
*
First Name
Last Name
📱 Parent/Guardian Phone:
*
📱 Parent/Guardian Phone:
*
Please enter a valid phone number.
📧 Parent/Guardian Email
*
example@example.com
📝 Types of Referral and Reasons
Check all the reasons that apply for the student’s referral to Therapy, Case Management, Med Managment or all. This helps Poppy’s match the student with the right services and supports.
📋 Type of Referral (Please check all that apply):
*
Therapy Referral
Case Management Referral
Family Therapy (Please Note: Family must be notified of family therapy referral)
Medication Management
Group Therapy
Day Treatment
🛋️📝 Reasons for Therapy Referral: (Check all that apply)
*
Persistent sadness or withdrawal
Anger outbursts or difficulty managing emotions
Threats to Self or Others
Anxiety or excessive worry
Difficulty focusing or paying attention
School avoidance or frequent absences
Behavioral/Discipline Issues
Decline in grades or motivation
Conflict with peers, teachers, and or authority
Conflict with Family
Family & Life Changes
Bullying (as victim or perpetrator)
Trouble making or keeping friends
Impulsivity or disruptive behavior
Bereavement Support
Client declines Therapy Services
Other
🗂️ Reasons for Case Management Referral
*
Basic Needs Support ( 👕 Clothing needs🥪 Food insecurity🛏️ Housing instability or homelessness💡 Utility assistance needs)
Educational Support (🏫 School attendance concerns / truancy📖 Academic struggles needing extra resources🎯 Special education or 504 plan coordination)
Social & Community Connections ( 👫 Limited peer relationships or social isolation🎟️ Lack of access to extracurricular activities🏀 Sports, arts, or recreation access support)
Family Support & Stability (💔 Divorce, separation, or family conflict⚖️ Involvement with child welfare or juvenile court🚗 Transportation barriers for school or appointments)
⚖️🩺 Legal & Medication Awareness/Assistance (⚖️ Support navigating legal concerns or court involvement💊 Assistance understanding or managing prescribed medications)
Mental & Behavioral Health Coordination (🗣️ Advocacy with school staff📋 Coordination between school, healthcare, and community agencies)
Client Declines Case Managment Services
Other
💳 Insurance & Coverage Details
Please provide the student’s current insurance or payer details. This information ensures accurate coverage before services begin.
💳 Payment Type
*
Medicaid
Medicare- Part B
Commerical/Private Pay
Self Pay
Other
🩺 Primary Insurance Provider:
*
Please Select
Aetna
Ambetter
Amerihealth
Anthem
Anthem Medicaid
Buckeye Health Plan
Caresource
Cigna
Humana
Humana Horizon Medicaid
Medical Mutual
Molina
OhioRise Aetna
Optum
United Healthcare
United Healthcare Community
UMR
Not Listed
Unknown
Forms Of Payment
*
Caresource
Molina
Anthem Medicaid
Buckeye
UHC Medicaid
Aetna Medicaid Plan
Ambetter
United Healthcare Commercial
Humana
Self-Pay
Unknown
Ohio Rise
AmeriHealth
🧾 Member ID (if available):
Additional Information (Optional)
Please list any additional information you would like to share with us.
🗂️ Reasons for Case Management Referral
*
Social, Behavioral, and Emotional Skill Building
Housing & Financial Stability (i.e.: Low Income Housing, Emergency Shelter Resources, Transitional Housing Resources)
Referral Coordination
Assisting with Developing and Utilizing Coping Skills
Job and Career Readiness
Education & Social Environment (i.e.: Social Interpersonal Skills)
Health Support (i.e.: medical resources)
Client Advocacy
Crisis Management and Prevention
Rent, Utility & Financial Resources
Clothing and Food
Substance Abuse
Medication Assistance
Legal Assistance
Client does not want Case Management
Additional Information:
Submit
Should be Empty: