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Referral Form
If it appears that the situation you are concerned about

Please call 9-1-1


The National Suicide Hotline

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.
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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 *
Your phone number *
Area(s) of Concern (check all that apply)* *
Please provide a short description of your concerns that prompted you to fill out this referral. *
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