--- title: School-Based Health to Whole Child Referral Form Template | Paperform description: Comprehensive school health referral form with trauma-informed care, ACEs screening, and academic-health integration for coordinated student support and educational success. url: "https://paperform.co/templates/school-based-health-to-whole-child-referral-form" type: static generatedAt: "2026-04-04T00:45:11.170Z" --- [← Back to free form templates](/templates/) ![School-Based Health to Whole Child Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/school-based-health-to-whole-child-referral-form.png) [Preview](https://_preview.paperform.co/ai-template/school-based-health-to-whole-child-referral-form) [Use this template for free](/create?ai-template=school-based-health-to-whole-child-referral-form) [Healthcare & Medical Forms](/templates/category/healthcare/)[Education Forms](/templates/category/education/) [Social Media & Content Creation](/templates/industry/social-media/)[Healthcare](/templates/industry/healthcare/)[Mental Health](/templates/industry/mental-health/)[Education](/templates/industry/education/)[Nonprofit](/templates/industry/nonprofit/) [Nurse](/templates/role/nurse/)[Therapist](/templates/role/therapist/)[Counselor](/templates/role/counselor/)[School Counselor](/templates/role/school-counselor/)[Social Worker](/templates/role/social-worker/)[School Administrator](/templates/role/school-admin/) About this free form template ### 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. Built for growing businesses, trusted by bigger ones. Trusted by 500K+ business owners and creators, and hundreds of millions of respondents. ![Capterra - 4.8 out of 5](/images/capterra-st.jpg) ![Trustpilot - 4.8 out of 5](/images/trustpilot-st.jpg) ![G2 - 4.8 out of 5](/images/g2-st.jpg) [Try Paperform free now](/register) ## More templates like this [![Anonymous Suicide Contagion Response Protocol & Postvention Reporting Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/anonymous-suicide-contagion-response-protocol-postvention-reporting-form.png) ### Anonymous Suicide Contagion Response Protocol & Postvention Reporting Form A confidential form for reporting gaps in suicide contagion response protocols and postvention practices. 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