School-Based Health to Whole Child Referral Form

Support Every Student with a Whole Child Referral System

School-based health services play a critical role in student success, but coordinating care across health, academics, and social-emotional needs can be challenging. This School-Based Health to Whole Child Referral Form is designed to bridge the gap between medical providers, school staff, and family support services through a trauma-informed, integrated approach.

Why This Template Works for School Health Programs

Traditional referral forms often silo physical health from mental health, academics, and family circumstances. This template takes a whole child approach, recognizing that student well-being depends on addressing health, safety, learning, and developmental needs together. It includes sections for adverse childhood experiences (ACEs) screening, trauma-informed observations, academic performance indicators, and coordinated care planning.

Perfect for school nurses, counselors, social workers, student support teams, and community health partnerships, this form streamlines referrals from school-based health centers to specialists, mental health providers, and wraparound services. It supports FERPA and HIPAA-compliant information sharing while maintaining student privacy and family engagement.

Key Features for Educational-Health Integration

• Student demographic and consent capture with emergency contact verification
• Reason for referral with academic-health connections to physical, behavioral, mental health, or family support needs
• Trauma-informed screening including ACEs indicators and trauma-responsive observations
• Academic performance context including attendance, behavior, and learning concerns
• Multi-disciplinary coordination for care team involvement and follow-up planning
• Conditional logic that adapts questions based on referral type and urgency level

Streamline Referrals with Paperform + Automation

This template is built on Paperform, giving school health teams a GDPR and SOC 2 Type II compliant platform that works across devices. When a referral is submitted, you can use Stepper (stepper.io) to automatically route urgent cases to counselors, send follow-up tasks to care coordinators, update student information systems, and trigger parent communication—all without manual data entry.

Use Papersign (papersign.com) to collect consent for services, release of information agreements, or care plan approvals digitally, keeping everything connected to the original referral for complete documentation and accountability.

Whether you're managing a school health clinic, coordinating student services, or leading equity and wellness initiatives, this template helps you move from fragmented referrals to cohesive, trauma-responsive care that supports the whole child and their educational journey.