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CASSY Counseling Referral Form
Please complete this form when referring a student for CASSY services.


1. SAFETY CONCERNS (student is having suicidal thoughts, self-harm behavior, or threatening to hurt someone else)
Needs immediate intervention
STOP HERE - No need to fill out form
CALL CASSY for risk assessment - or ESCORT student directly to CASSY and knock on office door.
If CASSY staff off campus contact an administrator, dial 222, or email

2. URGENT CONCERNS (anxiety/panic attack, possibly having suicidal thoughts, extreme emotional distress)
Needs to be seen ASAP within the day
Submit this electronic referral form.

3. GENERAL CONCERN (anxiety, depression, social, or family problems affecting school)
Can be seen within the next week
Submit this electronic referral form.

For academic concerns - please contact the student's Guidance Counselor.
For disciplinary concerns - please refer the student to their appropriate school administrator.
Untitled Title
Email Address *
Your answer
Student's Name *
Your answer
Referral Date *
Your answer
Referred By (name & relationship to student) *
Your answer
Student ID Number (Optional)
Your answer
Grade Level *
Areas of Concern *
How are concerns affecting student at school? *
Interventions Previously Attempted
Your answer
Other Relevant Information
Your answer
Level of Concern *
Parents Have Been Notified of Referral? *
Student is Aware of Referral? *
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