Center High School Mental Health Services Referral Form
If you have concerns about a student and would like the support of someone from your school's mental health team, please fill out the form below. Complete the entire form before submitting.
Parents/Guardian: If your concerns involve the student displaying/demonstrating self-harming thoughts or behaviors which you believe need immediate attention, please contact the National Suicide Prevention Lifeline at 1-800-273-8255, your school counselor or social worker, or other appropriate agency, dependant on your comfort level.
CSD staff: If the student is in imminent risk of harm to self, please follow established school-based protocol during school hours. If after hours, please follow the established school-based protocol in addition to attempting to contact parents and contact 911 as appropriate.
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Your last name
Your first name
Relationship to the student being referred?
Student last name
Student first name
Yellowjacket Early Learning Center
Boone Elementry School
Center Elementary School
Indian Creek Elementary School
Red Bridge Elementary School
Center Middle School
Center Alternative School
Center High School
Is the student currently receiving mental health services (e.g. outsdie therapy/counseling, medication to support mental health needs, history of in-patient treatment) ?
If answered yes to last questions, please provide additional information that would help in supporting the student.
Does the student have a health/safety plan?
Does the student have an IEP/504?
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This form was created inside of Center School District #58.