Referral Form

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Referral Form

If it appears that the situation you are concerned about
is an EMERGENCY,

Please call 9-1-1

~or~

The National Suicide Hotline
1-800-273-8255

If you truly believe that this situation is not an emergency, and that the person you're concerned about is not an immediate threat to themselves or others, please complete the referral form below.

Email *

Student Last Name *

Student First Name *

What grade is the student in?

Your Name (This will be received by the District Mental Health Navigator to be used for follow-up. All information is confidential per FERPA requirements.) *

Relationship to Student *

Teacher

School Support Staff

Guidance Counselor

School Administrator

School Nurse

Other

Your phone number *

Area(s) of Concern (check all that apply)* *

Academic concerns

Behavioral concerns

Social concerns

Emotional concerns

Physical Health

Family concerns

Other

Required

Please provide a short description of your concerns that prompted you to fill out this referral. *

Send me a copy of my responses.

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