Parent and Student Referral for Wellness Services

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

This form is available to students and parents who have wellness needs and concern. Please fill out this referral to start the process and a member of the Wellness Team will determine the next step.

Wellness referrals will be addressed Monday - Friday 8:30am to 2:30pm during the school year.

Email *

Student Information: (Name, Age, Grade) *

Best Contact for Student: (Day/Time on campus)

School: *

Referral Source *

Type of Service *

Wellness Check In

Mental Health Tools

Help with Referral to Mental Health in Community

Other:

Required

Reason for Referral *

Briefly describe the reason for this referral.

Safety Concerns Present?

If safety concerns are actively present, contact immediate support.
Call 911 and/or Call or Text Suicide Prevention Hotline 988

Form Completed By: *

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of EDCOE.

Does this form look suspicious? Report

Forms