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Office Referral Form Template

Streamline Communication for Effective Support and Intervention

Do you struggle with ensuring individuals receive the support they need? This Office Referral Form Template helps you efficiently communicate the need for additional services or interventions for individuals in your organization. You can facilitate timely support, document essential information, and keep your team aligned on the next steps while maintaining clear records for compliance and reference. With user-friendly design and WCAG-aligned labels, this template makes it easy to enhance collaboration and streamline your referral process. Explore the live template to get started.

Use this Template (FREE) Live Preview
Referral date
Is this an urgent referral?
Yes
No
Student full name
Student ID (if applicable)
Homeroom or primary teacher
Grade level
Date of incident
Time of incident
Location of incident
Please Specify:
Problem behavior(s)
Please Specify:
Perceived motivation
Obtain peer attention
Obtain adult attention
Obtain item/activity
Avoid task/activity
Avoid peer(s)
Avoid adult(s)
Unknown/Not sure
Other
Please Specify:
Others involved
None
Peer(s)
Staff
Substitute
Unknown
Other
Please Specify:
Did an injury occur?
Yes
No
Brief description of the incident (objective, factual)
If an injury occurred, was medical attention required?
Yes
No
Actions taken prior to office referral
Please Specify:
Parent/guardian contacted prior to referral?
Yes
No
If contacted, method(s) used
Phone call
Email
Messaging app/Portal
In-person
Note sent
Not applicable
Other
Please Specify:
Witnesses (names, if applicable)
Current plans or services (if known)
Behavior Intervention Plan (BIP)
Individualized Education Program (IEP)
504 Plan
English learner plan
None
Not sure
Administrative action taken
Please Specify:
Duration or details (if applicable)
Returned to class after office visit?
Yes
No
Follow-up required?
Yes
No
Referred to support services
Counselor
Psychologist
Social worker
Nurse
Special education team
Attendance team
None
Other
Please Specify:
Your full name
Your role
Teacher
Staff
Administrator
Counselor
Substitute
Other
Please Specify:
Your email
Your phone number
Signer full name (as signature)
Date signed
I certify the information provided is accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration depicting an office referral form for FormCreatorAI article

When to use this form

This template helps your team route people, requests, or cases to the right office without back-and-forth. Use it when front desk staff need to send a visitor, client, or vendor to a specific department; when managers escalate an issue to HR or Finance; or when a practice admin forwards a case to another site. It captures who is being referred, why, and what outcome you expect, so the recipient can act fast. For clinical handoffs, a streamlined Patient referral form may fit better. If a provider is referring to another provider, use the Physician referral form. For a broad, industry-agnostic handoff, you can start with our Referral form.

Must Ask Office Referral Questions

  1. Who are you referring (full name, role, and contact information)?

    This ensures the recipient knows exactly who the subject is and how to reach them. Clear IDs prevent mix-ups when multiple clients or employees share similar names.

  2. What is the reason for the referral and the expected outcome?

    Stating the context and goal helps the receiving team prioritize and respond correctly. It also sets shared success criteria.

  3. Which department, person, or location should receive this referral?

    Naming the destination routes the request without internal bounces. If you are unsure, offer a short list or dropdown to speed selection.

  4. How urgent is this request, and what is the latest date you need a response?

    Urgency and due date drive SLA and scheduling. It prevents silent delays and sets clear expectations.

  5. What supporting documents or prior notes should we review?

    Uploading files (brief summary, screenshots, records) gives the recipient enough context to act on first pass. For provider-to-provider handoffs, the Doctor referral form includes fields that keep clinical attachments organized.

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