Mt. Healthy South Referral Form

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.
👤 Referral Submitted By:*
✏️ Name of Person Making the Referral (Last, First):

First NameLast Name
👩‍🎓 Student Name:*

First NameLast Name
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
🗓️ Student’s Date of Birth:*

MonthDayYear
Date
🎂 Student’s Age:*
🎓 Grade Level:*
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 ?*

YesNoOther
Referral Initiated by (Last Name, First Name):*
Parent/Guardian Name (Last Name, First Name):*
👨‍👩‍👧 Parent/Guardian Name (Last Name, First Name):*

First NameLast Name
📱 Parent/Guardian Phone:*
📱 Parent/Guardian Phone:*
Please enter a valid phone number.Format: (000) 000-0000.
📧 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 ReferralCase Management ReferralFamily Therapy (Please Note: Family must be notified of family therapy referral)Medication ManagementGroup TherapyDay Treatment
🛋️📝 Reasons for Therapy Referral: (Check all that apply)*

Persistent sadness or withdrawalAnger outbursts or difficulty managing emotionsThreats to Self or OthersAnxiety or excessive worryDifficulty focusing or paying attentionSchool avoidance or frequent absencesBehavioral/Discipline IssuesDecline in grades or motivationConflict with peers, teachers, and or authorityConflict with FamilyFamily & Life ChangesBullying (as victim or perpetrator)Trouble making or keeping friendsImpulsivity or disruptive behaviorBereavement SupportClient declines Therapy ServicesOther
🗂️ 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 ServicesOther
💳 Insurance & Coverage Details

Please provide the student’s current insurance or payer details. This information ensures accurate coverage before services begin.
💳 Payment Type*

MedicaidMedicare- Part BCommerical/Private PaySelf PayOther
🩺 Primary Insurance Provider:*
Forms Of Payment*

CaresourceMolinaAnthem MedicaidBuckeyeUHC MedicaidAetna Medicaid PlanAmbetterUnited Healthcare CommercialHumanaSelf-PayUnknownOhio RiseAmeriHealth
🧾 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 BuildingHousing & Financial Stability (i.e.: Low Income Housing, Emergency Shelter Resources, Transitional Housing Resources)Referral CoordinationAssisting with Developing and Utilizing Coping SkillsJob and Career ReadinessEducation & Social Environment (i.e.: Social Interpersonal Skills)Health Support (i.e.: medical resources)Client AdvocacyCrisis Management and PreventionRent, Utility & Financial ResourcesClothing and FoodSubstance AbuseMedication AssistanceLegal AssistanceClient does not want Case Management
Additional Information:
🧾 Who is this Referral For?*
Should be Empty:

🌸 Mt. Healthy South Referral Form

Parent/Guardian Information

📝 Types of Referral and Reasons

💳 Insurance & Coverage Details

Additional Information (Optional)