The web Browser you are currently using is unsupported, and some features of this site may not work as intended. Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer.
Handle with Care for Mental Health Professionals
Sample Referral Forms for Mental Health Services
Sample Confirm Receipt of Referral Form
Sample Referral Status Update Form
Jackson Mental Health Referral Form
Washtenaw Mental Health Referral Form
When a child is exposed to violence or trauma and a law enforcement officer has contacted the child’s school and the school has determined that school-based mental health services are appropriate the following procedures will occur:
- A written consent will be obtained from the parent/guardian for care providers and school staff to communicate about the best interest of the child via a Release of Information and Parental Permission to Treat a Minor
- Upon completion of consents, a Clinical Referral Form will be completed and fax/emailed to the mental health provider (MHP) of their choice. The form will include current contact information for the child’s parent/guardian and will indicate the requested service (i.e.: psychological evaluation, intake for individual, family or group therapy)
- UPON RECEIPT of the referral and consents, the MHP will confirm receipt of the referral (download sample form)
- The MHP will initiate contact with the parent/guardian to schedule an intake at the time and location that works best for the student/family within 72 hours
- The MHP will notify the referring party of the intake date/time and location via fax/email. Note: If unable to reach the parent/guardian after 3 attempts in one week the MHP will mail a letter to the address on the referral form requesting they contact the office to schedule an appointment and will notify the referring party of inability to schedule (download sample form).
- If still unable to reach the parent/guardian the MHP may contact MDHHS to make a Prevention Referral and in person contact with the parent/guardian may occur.
- The referring MHP will provide intake package to the parent/guardian to complete and bring to intake appointment
- The MHP will complete the initial intake assessment and treatment plan. If therapy is recommended, the MHP will work with school personnel to determine the least disruptive time in the child’s schedule for therapy to occur
- The MHP will meet with the child in the designated space at the school
- The MHP will work with school personnel to establish procedures for child retrieval from the classroom and safe return to the classroom, adhering to child preferences
- The MHP will establish communication with the child’s teacher by submitting the Teacher Communication Letter to the child’s teacher (download sample form)
- The MHP will establish a communication mechanism with the parent/guardian regarding the child in a manner that does not burden the school system
- The MHP will notify the designated school personnel of therapists unscheduled absences or schedule changes
- The MHP will keep designated school personnel informed about status of therapy (active, inactive, terminating)
- The MHP will work with designated school personnel to attend SAT or other school based meetings as needed in the best interests of the child
- The MHP will provide trauma, or behavior specific training to school staff on an as needed basis and per MOU agreement with the County School system
- The MHP will leave the designated therapy space in acceptable condition, removing any confidential or identifying information from the premises.
- The MHP will participate in quarterly HWC Team Meetings to assess the following to determine the effectiveness of DCI/HWC: academic achievements; truancies; and disciplinary reports and treatment outcomes. The meeting will not focus on specific cases.
Handle With Care