Mental Health Referral Form Template
Facilitate warm referrals to mental health services with a structured form that captures the client's presenting concerns, current situation, and urgency — so receiving providers can prepare appropriately.
A referral that includes full clinical context is infinitely more useful than a name and phone number. When the referring provider captures the presenting concerns, relevant history, risk indicators, and the reason for referral in a structured format, the receiving clinician can prepare for the first appointment — and the client doesn't have to repeat their story from scratch.
This template covers the referring provider's details and role, client demographics and contact information, presenting concerns and clinical context, relevant psychiatric and medical history, current medications, risk assessment summary, urgency of the referral, the type of mental health service being sought, consent for information sharing, and the referring provider's signature.
Primary care providers, school counselors, hospital discharge teams, social workers, and community mental health workers use mental health referral forms when connecting clients to specialized mental health services. Route submissions to the receiving provider's intake coordinator. Connect to your case management system to track referral status from submission through first appointment.
Yes — include a consent to information sharing section. The client's authorization to share clinical information between providers is typically required.
Add a priority field (routine, urgent, emergent) and configure different notification workflows for each. Urgent referrals should trigger immediate outreach.
Share the submission with the receiving provider's intake team via email notification or connect to their intake system via integration.
Include crisis resource information in the form and note that emergency referrals should use emergency services. The form handles non-emergency referral coordination.
Add a follow-up tracking field to your case management workflow. Contact the receiving provider at a set interval after referral to confirm the client connected with services.
Get inspired by relevant templates and categories
3200+ Templates, 300+ Integrations
With Typeform, you can 
customize everything
Change text, colors, and even logos to match the look and feel of your brand. Then embed forms smoothly onto web and email.
Make forms feel effortless to fill out. Pace questions, call people by their name, and adapt the flow based on the data they share.
Stay efficient by connecting forms to your workflow. Typeform integrates with 300+ tools including Slack, Zapier, and HubSpot.
