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Lincoln Student Referral Form
Telebehavioral Health Services at The Health Center
Reach us by email at: help@thehealthcenterww.org
Or by phone at: (509)525-0704
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.
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Email *
Name of Person Completing this Referral *
Relationship to student: *
Student's First Name *
Student's Last Name *
Student's Date of Birth *
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What is the best phone number to reach the student? *
What is the address where the student is sleeping? *
Current School *
Grade *
Reason for Referral: Include brief mental health concerns and relevant information *
Was student informed of the referral and agreed to coordination between The Health Center and Walla Walla Public Schools? *
How does the student wish to be contacted? *
Please list anything else you would like to share here *
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