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Home • School Based Mental Health Referral Form

School Based Mental Health Referral Form

"*" indicates required fields

School Based Mental Health Referral Form

Student Information

Child Name*
Preferred Name
Teacher Name (Elementary Only)
Is the child aged 5 years or younger at the time of referral?*
Has the child previously been referred to services with People Incorporated?*
Is the child currently receiving mental health services or supports in home or community (examples: individual or family therapy, case management, skills worker)?*

Contact Information

*Please Note: A legal guardian is required to consent to services for clients under the age of 16 years old. If you are not the child's birth parent, or there are custody considerations, we require court or notarized documentation that indicates you have authority to medically consent to services. Please email this documentation to SBMHintakes@peopleincorporated.org. Youth 16 years and older can consent to outpatient clinical therapy (including school-based services) as well as outpatient medication management. Youth can still have parents/guardians consent if they choose.
Parent/Guardian Name*
Legal Guardian?*
Interpreter Needs?*
Second Parent/Guardian Name
Legal Guardian?
Interpreter Needs?
Preferred Billing Address*
Can voicemail be left identifying call from People Incorporated?*

Referral Information

Referent Name*
Referral Source Role*

Additional Services of Interest

Please indicate if this family may be interested in learning more about any of the following People Incorporated services. Completion of this section allows our team to provide information and discuss potential service options with the family. Select all that may apply.
Child & Youth Services
Adult Services

FOR REFFERALS FROM SCHOOL STAFF

Max. file size: 256 MB.
Does the student have an IEP?
Does the student have a 504 plan?

Insurance Information

*This section is not required, but providing this information may help to expedite the referral process.