TBI School Referral Form

Please correct the errors described below.

Instructions:

Please complete this secure HIPAA-compliant form to refer a student for services with Therapeutic Behavioral Interventions (TBI). A member of our team will contact the family within 24–48 hours.

School Counselor Information:

School Counselor Name:

School Name:

School Counselor Phone Number:

School Counselor Email:

Student Information:

Student Full Name:

Student Date of Birth:

Grade

Teacher/Classroom

Parent/Guardian Name:

Parent/Guardian Phone Number

Parent/Guardian Email Address

Parent/Guardian Name:

Parent/Phone number:

Parent/Guardian Email Address

Reason for Referral

Primary Concerns

Anxiety

Depression

Emotional Regulation Concerns

Behavioral Challenges

Peer Conflict

Social Skills Concerns

Trauma Concerns

Academic Stress

Attendance Concerns

Family/Home Stressors

Adjustment Issues

Other

Brief Description of Concerns:

Services Requested

Services

School-based therapy at student's school

Outpatient therapy at TBI office

Parent support/consultation

Teacher consultation

Not sure-please determine appropriate service(s).

School Supports Information

IEP or 504 Plan?

Behavior Plan in Place?

Has the parent/guardian been informed of the referral?

If no, please explain:

Safety Concerns/Additional Notes:

Describe any safety concerns/additional notes:

Your information will be encrypted.

Instructions:

Please complete this secure HIPAA-compliant form to refer a student for services with Therapeutic Behavioral Interventions (TBI). A member of our team will contact the family within 24–48 hours.

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