Student Referral for Mental Health Support

Student Referral for Mental Health Support

A form to refer a student for school-based mental health services.
Urgency of Referral
This form is only appropriate for ROUTINE referrals. If your referral is urgent or emergent, contact your administrator immediately and follow your school's crisis protocol.
NOTE: This webform will not collect the patient's name or date of birth. We will collect that information when we reach out to you.

Would you prefer filling out this referral on our formal PDF form instead?

Click here to download a formal PDF Version of the School-Based Mental Health Referral Form. When complete, you can upload your completed form or school-specific form here or return by fax to (301) 381-8814
Referring Teacher's Full Name

First NameLast Name
Teacher's Email Address
example@example.com
School Name
Student's Grade or Class
Should be Empty: