Request edit access
WaHi Student Referral Form
Telebehavioral Health Services at The Health Center
Reach us by email at:
Or by phone at: (509)562-8674
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 one week.
Sign in to Google to save your progress. Learn more
Email *
Name of Person Completing this Referral *
Relationship to student: *
Student's First Name *
Student's Last Name *
Student's Date of Birth *
What is the best phone number to reach the student (THC can call but cannot receive or send text messages)? *
What is the address where the student is sleeping? *
Current School *
Grade *
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Health Center. Report Abuse