Complete this form to refer a student to site-based therapeutic services. Anyone can make a referral and students can self-refer. Site-based Licensed Mental Health Professionals cannot work with students who are already receiving therapeutic services in the community.

This form is not intended to make a referral for crisis situations. 

*If you have concerns that a student is at risk of harming themselves or others, call the Oklahoma Crisis Line at 988 or 911. 

*If you believe that a student is being abused, make a referral to DHS at 1-800-522-3511.

*If you need immediate crisis assistance, call the Mobile Crisis Response Unit at 1-833-885-2273.

The responses to the form will be seen by program staff and will be used to determine eligibility for services.