Solutions Counseling In-School Mental Health Referral Form
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2Solutions Counseling In-School Mental Health Referral Form
For more information on the in-school mental health program, visit STMA’s In-School Mental Health page at Solutions Counseling ().
Staff Referring
Your Name________________________________ Phone _________________________Email________________________________________
School Referral Location (circle one): HS
/ MSE
/ MSW
/ Fieldstone / STME
/ Big Woods / Primary
Checklist
Call parent and review the following:
Reason for referral. Review checklist of “When to Refer a Child…” Use this to help frame a conversation with the
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parent/guardian.
STMA has a contract with Solutions Counseling to provide in-school mental health services. They do not work for the school but
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provide services in the school. More about Solutions at .
Program is like traditional outpatient mental health services except, because it is held in the school, it eliminates the need for
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transportation and time off from work to get the child to services. It also allows important and ongoing care coordination with
involved school personnel (if appropriate).
Goal of the program is to help improve child’s ability to function at their best in school, at home, and with friends.
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st
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meeting requires a parent/guardian to be present. These meetings can be held outside of the school day if needed. Solutions
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can help you with finding a time that works best.
Solutions works with the school to avoid pulling the child out of core classes
whenever possible.
Program utilizes students insurance. If there are financial challenges preventing the use of services, Solutions has options to help.
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They can go over those options at the initial call with them.
Can STMA have verbal permission to release the name of the student to Solutions Counseling for the purposes of setting an
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appointment?
Referring party complete page 1 of this form. Fax to 763-497-0552. No cover sheet needed. Solutions will follow up with the parent and let
them know they have received a referral for in-school mental health services from you. Solutions will make up to three attempts to
contact the parent (typically one contact per 1-2 business days). If the parent does not respond, Solutions will contact the referring party
and alert them to the problem.
IF ABLE TO GET RELEASE SIGNED: Complete page 1 and 2. Attach signed release of information to have clinician coordinate care with school
personnel. STMA School Release made out to “Solutions Counseling” or Solutions pre-completed STMA release may be used for this.
Student Information
Student name_________________________________________________________________________Sex_____Grade_______ Age_______
Parent/Guardian Information
1.
Briefly, is there any information about the parent/guardian(s) that is important to know before Solutions calls? For example, high conflict, divorce
issues, criminal issues? YES / NO / UNSURE
2.
Does parent/guardian want more information about financial assistance? YES / NO / UNSURE
Parent/Guardian name(s)_______________________________________________________Phone(s)____________________________________
Relationship to Child___________________________________________Email______________________________________________________
Do they know we will be calling? YES/NO
This is the best parent/guardian to contact in order to expedite the start of services
Parent/Guardian name(s)_______________________________________________________Phone(s)____________________________________
Relationship to Child___________________________________________Email______________________________________________________
Do they know we will be calling? YES/NO
This is the best parent/guardian to contact in order to expedite the start of services
IS A RELEASE SIGNED?
NO:
STOP & FAX PAGE 1 TO SOLUTIONS AT 763-497-0552
(NO COVER REQUIRED)
YES:
CONTINUE TO PAGE TWO
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