Student Telehealth Referral Form
Share the minimum information needed to coordinate a student telehealth referral.
Student name
*
First Name
Last Name
School and grade
*
Parent/guardian name
*
First Name
Last Name
Parent/guardian email and phone
*
Referral source/name
*
Broad reason for referral
*
Support with school participation or routines
Help accessing telehealth services
Follow-up on a general support request
Other nonclinical coordination need
Referral urgency
*
Routine — no immediate follow-up needed
Soon — follow-up requested within a few days
Time-sensitive — please contact me as soon as practical
Preferred appointment availability
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Preferred contact method
*
Email
Phone call
Either email or phone
Submit referral
Should be Empty: