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CASSY Referral for Telehealth Services
Due to the current shelter-in-place order for Santa Clara County, counseling sessions will now be provided through TELEHEALTH (VIDEO/PHONE) SERVICES for the remainder of the school year.

PLEASE NOTE:
* If you are experiencing a medical or psychiatric EMERGENCY: call 9-1-1 or go to your nearest hospital.
** If you are concerned that someone is an IMMEDIATE DANGER to themselves or another person: call 9-1-1 or contact your local law enforcement . You can also request that a Crisis Intervention Trained (C.I.T.) officer do a welfare check for concerns regarding the safety.
*** If you need IMMEDIATE support: contact one of the crisis resources provided below:

CRISIS LINES AND WEBSITES
- Lifeline Crisis Chat: crisischat.org
- Crisis Text Line: 1.800.273.8255 or Text BAY to 741741
- OnYourMind Teen Chat (M-Th, 4:30-9:30 pm): onyourmind.net
- California Youth Crisis Line (CYCL): 1.800.843.5200
- Bill Wilson Center's 24/7 Teen Line for Youth: 1.888.247.7717
- Bill Wilson Center's SOS Crisis Hotline: 408.278.2585
- Santa Clara County Crisis Line: 855.278.4204

SUICIDE PREVENTION HOTLINES
- National Suicide Prevention Hotline: 1.800.273.8255
- Santa Clara County Suicide and Crisis Hotline: 1.855.278.4204

MOBILE CRISIS UNITS
- Alum Rock Mobile Crisis: 408.294.0579
- 24 hour Uplift Mobile Crisis Team: 408.379.9085 or 1.877.41.CRISIS
PLEASE REVIEW THE FOLLOWING GUIDELINES BEFORE PROCEEDING:

1. FOR IMMEDIATE SAFETY CONCERNS (current suicidal thoughts or threats with a plan or means to harm oneself or someone else)
* STOP HERE and DO NOT continue completing this form.
* IMMEDIATELY contact 9-1-1 or one of the crisis resources listed above.

2. FOR URGENT CONCERNS NOT INVOLVING IMMEDIATE SAFETY (severe anxiety or depression, panic attacks, passive suicidal thoughts, or extreme emotional distress)
* Please continue with this form and utilize the crisis resources provided above if immediate support is needed.

3. FOR GENERAL MENTAL HEALTH CONCERNS (anxiety, depression, social, or family problems affecting academic functioning)
* Please continue with this form and utilize the crisis resources provided above if symptoms worsen.

4. FOR ALL ACADEMIC or EDUCATION RELATED CONCERNS
* Please STOP HERE and contact the student's guidance counselor.
(For more information visit: LGHS.net > Guidance > Guidance Home).

5. FOR ALL DISCIPLINARY CONCERNS or REPORTS REGARDING INAPPROPRIATE STUDENT CONDUCT
* Please STOP HERE and contact a school administrator.
(For more information visit: LGHS.net > About Us > Administration)
STUDENT'S FULL NAME *
Your answer
STUDENT‘S ID NUMBER
Your answer
NAME OF PERSON REFERRING *
Your answer
RELATIONSHIP TO THE STUDENT *
HAS THE STUDENT BEEN SEEN BY CASSY BEFORE?
AREA(S) OF CONCERN *
Required
CURRENT IMPACT ON DAILY FUNCTIONING *
Required
WHAT HAS ALREADY BEEN TRIED TO ADDRESS THESE CONCERNS? *
Your answer
OTHER RELEVANT INFORMATION?
Your answer
IS THE PARENT/GUARDIAN AWARE OF THE REFERRAL? *
IS THE STUDENT AWARE OF THE REFERRAL? *
WOULD YOU LIKE TO REMAIN ANONYMOUS? *
LEVEL OF URGENCY (please read all options before making a selection) *
Required
DISCLAIMER: ALL REFERRALS ARE CONFIDENTIAL UNLESS THERE ARE CONCERNS OR REASONABLE SUSPICION THAT THE STUDENT OR ANOTHER PERSON’S SAFETY IS AT RISK. IN ORDER TO PROVIDE COMPREHENSIVE SUPPORT TO ALL STUDENTS, PLEASE BE ADVISED THAT COMMUNICATION BETWEEN THE CASSY TEAM & LGHS STAFF MAY OCCUR AT ANY TIME.

CASSY therapists will make THREE ATTEMPTS to contact students that are referred.
PLEASE NOTE: If a student does not respond to the attempts made to contact them, they will be considered a “no show” and subject to CASSY’s NO SHOW POLICY.

CASSY’s NO SHOW POLICY: For new referrals AND current clients, three “no shows” (to scheduled appointments or attempts made to contact the student) will result in a forfeiture of services. Students will be notified via email in the event that services are forfeited.
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