Cerro Gordo Community Unit School District 100

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Cartwheel Interest Form

Mental Health Support for Students & Families

In partnership with Cerro Gordo Community Unit School District 100, Cartwheel provides students and families with mental health support via teletherapy. We support students with a variety of challenges they may be facing like anxiety, depression, stress, social issues, and more.

What Happens After You Submit This Form?

  • A point of contact and/or school counselor at your child's school will be informed and review the request.
  • The school counselor will determine if Cartwheel is the appropriate support for your student.
  • Once approved, one of Cartwheel's Care Coordinators will reach out to you to schedule an initial intake appointment

Who can complete this form?

This form must only be completed by a legal guardian of the student, a student over the age of eighteen (18), or a student who otherwise meets age or criteria to consent for health care services in their state of residence. If you are not the legal guardian of the student or a student who meets this requirement, please share this form with them.

In Case of Emergency

Cartwheel does not provide urgent, crisis, or emergency care. In case of a medical or psychiatric emergency, please call 911 and bring your child to the nearest emergency room.

Prefer to start over the phone?

Call or text us at (617) 272-7439. We’re available Monday–Friday, 8 AM–8 PM, and Saturday, 8 AM–6 PM.

Consent and Communication Agreement

  • I am an authorized legal representative of the student, or I am over the age of eighteen (18), or of an age where I am authorized under state law to consent to mental health treatment, or I am an emancipated minor.
  • I agree to receive text messages and phone calls from Cartwheel to my phone number and emails from Cartwheel to my email address. I am aware that mobile message and data rates may apply.
  • I authorize Cartwheel Care Inc. on behalf of its affiliated medical practices (“Cartwheel”) to disclose the information I provide in the Cartwheel Family Self Identification Form to Cerro Gordo Community Unit School District 100 in accordance with the terms of the HIPAA Authorization for Release of Protected Health Information