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Middle School Student Referral Form
Mental Health Services at The Health Center
Reach us by email at: Pioneer@thehealthcenterww.org
Or by phone at: (509)525-0704
If you have an immediate safety concern, you need to call the crisis line: 509-524-2999 or 9-1-1
The Health Center will respond to this referral within 72 hours.
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Email *
Name of Person Completing this Form Relationship to Student *
Is the student currently seeing a counselor in the community? *
Student's First Name *
Student's Last Name *
Student's Date of Birth *
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DD
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Does the student have one of the following on file with the school? *
What is the address where the student is sleeping? *
Current Grade *
Required
If Student is Over 13, what is their preferred contact information?(ie. cell phone, school email) *
If Student is Under 13, name of Parent/Guardian and their preferred Contact Information (ie Phone number and email) *
If Over 13, Has the Student Been Notified of the Referral? *
If Under 13, Have the Student's Parent or Guardian Been Notified of the Referral? *
Reason for Referral: Please provide 1-5 sentences of the behavior and concerns observed by staff and/or parents that have led to this referral. *
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