Hamilton County School-Based Therapy Referral Form

Mental health support for Hamilton County students — in-person at school.

Thrive Therapies partners with Hamilton County Schools to offer free, school-based mental health services designed to support student's well-being, while protecting instructional time and prioritizing family involvement.

If your student attends Hamilton County Schools in Tennessee, we are located on-site and provide services throughout the school day. You can begin the referral process by completing our online form.

Please consider referring a student if you notice:
- Increased sadness, worry, or withdrawal
- Sudden behavior changes or mood swings
- Difficulty concentrating or staying engaged
- Signs of stress related to home, peers, or school
- Struggles with loss or trauma
- Verbalizing thoughts of self-harm or hopelessness
⚠️ Important:
This form is not for emergencies like abuse, neglect, or serious thoughts of harm. If that’s the case, please talk to the school’s mental health clinician or a trusted adult right away.

Para la versión en español de este formulario, haga clic aquí: Formulario de referencia para terapia escolar del Condado de Hamilton
Parent/GuardianSchool Staff MemberPrimary Care ProviderSelf - Referral (*clients under the age of 18 years old require parent/guardian consent)Other
Name of person filling out the referral form:*

First NameLast Name
Contact information for individual completing the referral form (phone and/or email): *
You will receive confirmation upon receipt of this referral.
Student's Name:*

First NameLast Name
Student's Date of Birth

MonthDayYear
MaleFemalePrefer not to say
Student's current grade:
Name of school the student is currently attending:*
YesNo
YesNo
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email:
example@example.com
Relationship to student:
IEP504NoI'm not sure
(Optional) Briefly describe what's been observed or why you think support could be helpful:
School staff (counselor, teacher, administrator)My child's school shared information with meAnother parent or family memberPediatrician or healthcare providerGoogle or another search engineFacebookInstagramSchool event / family nightCommunity EventEmail or flyer from the schoolOther (please specify below)
Please briefly explain if you selected "other" above:
Once this referral is received, Thrive Therapies Group will contact the caregiver directly to share additional information about our on-site school-based mental health therapy services. Thrive will also provide the required consent forms for caregivers to review and sign before services begin.
Should be Empty: