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

Who is filling out this referral?

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

Student's Gender:

Student's current grade:

Name of school the student is currently attending:

Student's availability to meet with a therapist:

Does the student know about this referral?

Are parents/guardians aware of referral? (Parent/guardian consent is required for minors under the age of 18 years)

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:

Does the student have an IEP or 504? (An IEP or 504 Plan is a school plan that gives extra help or support for learning, behavior, or health needs)

(Optional) Briefly describe what's been observed or why you think support could be helpful:

(Optional) How did you hear about Thrive Therapies?

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.

Profile created in Simple Practice?

Consent/Insurance info sent?

Consent signed?

Insurance info complete?

Outreach attempts

Additional notes

Assigned therapist

Sessions started?