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Online Referral Forms


Interested in School Linked Mental Health?
Please fill out the forms at the following links, and someone will contact you. You will need your child's health insurance information and social security number to complete these forms. If you do not have these items available or would like to provide them at a later time, you may submit these forms without that information.

Links to individual forms:

      Release of Information- Pine Island Public Schools (required)

      Parent/Guardian Consent Form
      Demographic & Financial Information
      COVID-19 Waiver
      Grievance/Privacy/Rights and Responsibilities
      Release of Information- MN Department of Health and Human Services (click "YES" on the question that asks if this  is for school linked mental health)

Prefer a paper version? You may also print this form, fill it out, and return it to your child's school counselor: Release of Information
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