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Chaparral-Vista Mental Health Referral
*** IF THIS IS AN URGENT REFERRAL, SUCH AS IMMINENT DANGER OR CONCERNS ABOUT SAFETY, PLEASE CALL 9-1-1 OR THE NATIONAL SUICIDE HOTLINE AT 988 OR 1 (800) 273-8255 (TALK) IMMEDIATELY***
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Email
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Your email
Name of person submitting referral:
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Your answer
Preferred method of contact for person submitting referral:
Please include your phone number or email so that we can follow up with you!
Your answer
Referred by:
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Choose
Self
Student behalf of another student
Teacher
School Staff
Parent/Guardian
Student's Name
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Your answer
Mental Health Concerns
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Grief or loss
Depression
Anxiety
Bullying
Suicidal ideation or self-harm
Trauma
Eating-related concerns
Stress
Relationship concerns
Substance use
Family concerns/conflict
Other:
Required
Please describe your primary concern and your reason for the referral (be specific):
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Your answer
Thank you for asking for help--it is a courageous act, whether for yourself or another! You will be contacted by a mental health support specialist to discuss these mental health concerns. Thank you!
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