School Based Mental Health Services Referral — Online Form

Online Form

Completed by school staff to refer a student and their family to TSA's School Linked Mental Health Services.

Prefer paper? Download the PDF version All forms

School Linked Mental Health Services Referral Information

Date of Referral

Client and Family Information

Identified Client Name *

DOB *

Age

Sex *

Grade *

School *

Race *

Resides With *

Parent #1 Name *

Parent #2 Name *

Other Family Members

Name	Relationship

Legal Guardian of Identified (Minor) Client *

Previous TSA Client

Family Address *

City *

Zip *

Family Phone *

Name

Whose phone number is this?

Work Phone *

Name

Whose phone number is this?

Cell Phone *

Name

Whose phone number is this?

*Parent/Legal Guardian Email (required) *

*Parent/Legal Guardian Email

*Proof of custody is required when the referred child is in the temporary physical or legal custody of another party.

Other Current Service Providers

County Worker *

Probation *

Psychiatrist

GAL

Primary Care

CTSS Worker

Mental Health Agency

Referral Information

Referring Person *

School

Phone # *

E-Mail

Release of Information secured

Written / Verbal

If written, please fax along with referral form

Reason for Referral/Presenting Problem/Brief History *

Other information

Previous or Existing Diagnosis Information

Diagnostic Assessment completed

DA is CTSS compliant

If yes, services may begin

Date of DA

Who completed DA

How can TSA get a copy of DA?

Insurance/MA

Insurance Company *

ID/PMI# *

Group # *

Subscriber Name *

Subscriber D.O.B. *

Subscriber Employer *

Subscriber Address *

Completed forms may be faxed to 651-925-0071 or please call our Intake Dept at 320-629-7600.

Download the PDF instead

Submissions are transmitted over an encrypted connection and stored securely for the TSA intake team. Typing your name in a signature field constitutes your electronic signature.