RSD Student Referral Form

"*" indicates required fields

Referring Person

Name*

First Last

Email*

School*

Student Information

Returning Student?*

Has this student worked with Larch in the past through our RSD program?

Location of Past Engagement*

What school were they attending during their past engagement?

Past Counselor?*

If unknown, put NA

Student Name*

First Last

Student Email*

Student Phone #

Grade*

Student Age*

Parent

Parent/Guardian Name*

First Last

Parent/Guardian Email*

Parent/Guardian Phone

Hidden

(Hidden) End Parent Section

Recommended Day/Time

Reason for Referral*

Access Code

Enter Access Code to submit*

What is the School Based Mental Health Therapist Program?

The School Based Mental Health Therapist program is a partnership between Riverview and Larch Counseling, designed to meet the needs of students who could benefit from psychotherapy (Mental Health Counseling), and do not have the ability to get that support on their own outside of the school setting (or in the case during remote learning, outside the schools support and funding). We encourage you to first assess if a student can get support outside through our practice or another therapist in the community.

We use the term “Therapist” instead of “Counselor” to help distinguish the type of relationship and work our specific role carries. We are engaging in psychotherapy (more commonly referred to as mental health counseling), and are supporting the students at a deeper level. Another reason we use this term is to distinguish between the FERPA and HIPPA guidelines. Our program operates under HIPPA, and with that, have stronger privilege for the confidentiality of the students we are meeting with.

Who Can Refer?

School Counselors, Principals, Vise Principals and a few other select approved RSD staff members. We have expanded it to include more than just the school counselors in case a student feels more comfortable with the admin staff. The main process will be through the school counselors.

Candidates for referrals include the following:

*Students who do not have strong family involvement, and would not be able to get support outside the school setting

*Students who do not have the family resources to pay for outside services

*Students who have low agency and motivation to get support without strong guidance and support from the RSD

*For students who are 13 and older, and have a family system who does not want them to get outside support in psychotherapy, or who do not feel safe having their family know they are getting support

How To Refer?

1) The preferred method is to complete the RSD Student Referral Form at the top of this page. This will allow us to gather all the appropriate information we need to send them the correct electronic intake paperwork.

2) Talk to the School Based Mental Health Therapist that is placed at your school, and they can help get the student set up. This is often used when students need the support of a therapist helping them complete the paperwork in a hard copy form in the school setting.

What If A Student Does Not Fit The Criteria?

If a student does not fit the criteria for Larch’s School Based Mental Health Therapist Program, you can refer them to our organization for therapy at our Duvall or North Bend offices, or refer them to another practice. Below are a few referrals

*Larch Counseling Website

*Unified Counseling Website

*Psychology Today, a local Directory – Website