JEBMS Mental Health Support Referral Form

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

JEBMS Mental Health Support Referral Form

This form is not intended for emergency or time sensitive situations (suicidal ideation, disclosure of abuse/neglect, etc.). In the case of an emergency, you can dial 911 or you can call the Suicide and Crisis Lifeline at 988. Local crisis lines include LifeSkills (1-800-223-8913) and Rivendell Behavioral Health Hospital (1-270-843-1199). If you are in need of immediate assistance between the hours of 7:30am - 4pm, please contact Liz Young - (270) 622-7140 EXT 4093) and then complete the form.

This form does not alleviate you from mandated reporting of suspected abuse or neglect. If you need to make a child welfare report to child protective services please call 1-877-597-2331or visit (online reporting) https://prd.webapps.chfs.ky.gov/reportabuse/Home.aspx

Email *

Student's name (Last, First) *

Person making the referral: *

Referral Date *

YYYY

Relationship to student: *

Teacher

School Counselor

Staff (Bus Driver, etc.)

Administrator

Peer

Parent

Case Manager

Other

Required

Student's Grade *

Reason for referral (Check all that apply) *

Personal Safety

Peer Relationships

Withdrawal

Grades

Attendance

Emotional

Family issues that concern the student

Prolong or frequent changes in affect (moodiness, anxiousness, sadness, weariness, anger, etc.)

A loss (such as death of family member/pet or friend, divorce, move)

Conduct problems

Other:

Required

Level of concern: 1– not at all concerned, 2– Slightly concerned, 3– Somewhat concerned, 4– Moderately concerned, 5– Extremely concerned
*

Not at all concerned

Extremely concerned

Please provide a brief narrative in regards to each checked area of concern. Please include the approx. date the concern was noticed and what has been done (if anything) to address this concern thus far:
*

Student's strengths *

Is the student aware of the referral? *

Yes

Best time of day to see the student *

Is the parent/guardian aware of the referral? *

Yes

Is the parent/guardian aware of your concerns? *

Yes

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Allen County Schools.

Does this form look suspicious? Report

Forms