School Partnership Program:
Student Mental Health Referral Portal

A streamlined, HIPAA-compliant way to connect students and families with timely, quality outpatient mental health care. This referral pathway is designed for school counselors, social workers, school psychologists, nurses, coaches, and administrators.

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Mission & Vision

Our vision is to establish a school-aligned mental health referral system that improves access to timely, evidence-based care while reducing barriers for students, families, and school professionals.

Several of our clinicians are also certified school social workers, who hope for a future where every student has timely access to compassionate, consistent mental health care—and where schools have a trusted partner to help support the wellbeing of their students and families.

If we do not have availability that meets the needs of your student, our clinical and administrative staff will work to connect your student to appropriate resources in a timely manner.

How It Works:

🚦 Student Referral Decision Guide

Start Here: Is there immediate safety risk?

Examples:

Suicidal thoughts with plan or intent
Recent suicide attempt
Risk of harm to others
Unable to stay safe
Psychosis or severe disorientation

👉 YES → Emergency / Crisis Support
Call 211, 911, 988, or follow your school’s crisis protocol
Do not submit an outpatient referral

👉 NO → Continue Below

Is the concern urgent but not emergent?

Examples:

Suicidal thoughts without plan/intent
Escalating self-harm (non-lethal)
Severe anxiety or emotional distress
School refusal or major behavioral changes

👉 YES → Outpatient Referral
Submit referral with parent/guardian consent
(We recommend increased school support)

👉 NO → Continue Below

Outpatient Therapy May Be Appropriate

Examples:

Anxiety, stress, or mood concerns
Peer or social challenges
Family changes or conflict
Behavioral or adjustment concerns

👉 Submit Referral with Parent/Guardian Consent

Not Sure?

We’re happy to consult with school staff to determine the most appropriate level of care.

Get Started

The benefits of this school collaboration:

Local clinicians who understand the community
Consistent therapist (not rotating providers)
Insurance + private pay options
Timely access to care
Additional resources to help support families

The process:

Submit referral form (with parent consent)
We contact the family within 2 business days
Intake scheduled within 3-5 business days
Community referrals coordinated if applicable
Ongoing therapy begins
Optional coordination with school (with consent)

Student First Name

Student Last Name

Date of Birth

Month

Day

Year

School

Grade Level

Insurance Provider, ID#, Group#, Primary Policy Holder Name

History/description of presenting problem(s)

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Parent/Guardian Name (if student is under age 18)

Parent/Guardian Address

Contact Email (Parent/Guardian email if student is under age 18)

Phone (Parent/guardian phone if students is under age 18)

By submitting this referral, I confirm that I have obtained parent/guardian consent to share this information and to be contacted regarding services. The release form will be provided. I understand that this referral does not guarantee immediate services or crisis response, and that emergency situations should be directed to 211, 911, 988, or appropriate school crisis protocols.

Signature of person providing referral

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Referral Source (Name)

Professional Role

Referral Release Form Upload

School Partnership Program: Student Mental Health Referral Portal

Mission & Vision

How It Works:

🚦 Student Referral Decision Guide

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Start Here: Is there immediate safety risk?

Is the concern urgent but not emergent?

Outpatient Therapy May Be Appropriate

Not Sure?

Get Started

School Partnership Program:
Student Mental Health Referral Portal