School*

Student Name:*

DOB:*

Grade Level:*

Parent / Guardian Name:*

Phone Number*

Primary Language:*

IEP / 504 Plan?*

Yes

No

Referred By:*

Role / Title:*

Email:*

Phone:*

Date:*

Reason for Referral (Check all that apply)*

Behavioral & Social Concerns:

Emotional & Mental Health:

Academic & Attendance

Behavioral & Social Concerns (Check all that apply):*

Frequent classroom disruptions / Defiance

Physical or verbal aggression

Social Withdrawal / Peer Difficulties

Sudden or Dramatic Shift in Behavior

Other

Emotional & Mental Health (Check all that apply):*

High Anxiety , worry, or panic

Persistent sadness, crying, or low mood

Difficulty managing anger or frustration

Suspected Trauma or major stressful event

Other

Academic & Attendance*

Sudden Drop in academic performance

Chronic Absenteeism or Tardiness

Severe Focus / Inattention Issues

Frequent visits to nurse / office without physical illness

Other

Additional Details of applicable*

Parent / Guardian has been notified of this referral.*

Yes

No

Date*

Parent / Guardian is supportive of behavioral health services*

Yes

No

Referring Staff Signature*

Date*

Sherwood Behavioral Health

School Behavioral Health Referral Form

Submit secure patient referral details directly to our clinical intake department. We process court-ordered evaluations, mental health assessments, and continuity of care transitions within 48 business hours.

School Behavioral Health Referral Form

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