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Counselor Referral Form
Please use this form to submit a referral to Mrs. Schubert.

Please note: This form is not to be used in an emergency. If you have a concern about the safety of a young person, please seek immediate help using the hotline numbers below, contacting local authorities or by alerting their guardian directly. This is especially important when school is not in session. Thank you!

NATIONWIDE CHILDREN'S HOSPITAL 24 HOUR CRISIS LINE
FOR CHILDREN UNDER THE AGE OF SEVENTEEN
614-722-1800
Mental Health and substance abuse services for Franklin County, Ohio. Available 24 hours a day, 365 days a year.

NATIONAL SUICIDE PREVENTION LIFELINE
1-800-273-TALK (8255)

24HR. CHILD ABUSE HOTLINE
614-229-7000

Email address *
Name of Student *
Your answer
Grade of Student *
Name of Referring Individual and best method to contact you. *
Your answer
Brief description of the concern *
Your answer
I think this child could benefit from a potential small group. (Click all that apply.)
Submit
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