Refer Your Student To Fort

This form is designed for school counselors, social workers, psychologists and special services staff.

The form is HIPAA-compliant and will enable you to refer your student for intensive individual support (therapy and/or psychiatry) with Fort Health.

We will reach out to your referral within 1 business day and inform you when we’ve been in contact with them.

Note: if your student requires a medical clearance to return to school, please specify it in the referral notes.

Please also provide your direct contact information below so that we can keep you updated. For any questions, email refer@FortHealth.com. Please note at this time Fort only accepts referrals for students residing in New York, Pennsylvania, and New Jersey.

Student Information

Child First Name*

Child Last Name*

State*

Child Date of Birth*

Child Sex Assigned at Birth*

This student or their legal guardian has consented to receiving email and text messages from Fort Health*

Parent or Guardian Information

Relation to Student*

First Name*

Last Name*

Phone Number*

Email*

Referring Staff Member

Name of School or School District*

Staff Member Name*

Staff Member Email*

Staff Member Position*

Office Phone Number*

Office Fax Number

Referral Notes

If you are experiencing a mental health emergency or medical emergency, please call “911” or 1-800-273-TALK (8255) to reach a crisis center or text 741741 to reach the Crisis Text Line.

* This student or their legal guardian, as may be required, has agreed to receive communications, including emails and text messages, from Fort Health regarding this referral and accessing health care, treatment, and services, and has provided their e-mail address and mobile phone number for the purpose of receiving these communications. The student/guardian has acknowledged the risks that may be associated with receiving health information via unsecured email or text messaging.