Request edit access
Student Supports Referral
This program is designed to provide supports for students who are experiencing social emotional and/or behavioral health concerns. USD 329 has created a partnership with Crosswinds Counseling and Wellness to provide supports for students during the school day. All information provided on this form will be sent directly to the Mental Health Intervention Team (MHIT) when selecting "submit" at the end of this form.

A member of the MHIT may reach out to follow up and gather more information after this referral.
Sign in to Google to save your progress. Learn more
Student Name *
Student's School Building *
Please describe your observations and concerns. *
Has the parent/guardian been made aware of these concerns? *
Has the parent/guardian been made aware of our school mental health program?   *
What interventions have we already tried using to address this concern? *
Does this student currently receive services? (Special Education or Mental Health) *
Name/Position of Staff Submitting Form *
Additional Comments/Concerns
Clear form
Never submit passwords through Google Forms.
This form was created inside of Wabaunsee USD 329. Report Abuse