Gateway Student Support Referral Form
Please use this form to submit a referral of a student for services provided at Gateway High School. This referral will be processed by a joint team representing school counseling, social work, mental health and Communities In Schools. Once submitted, you will receive a detailed follow-up from the team.
Please verify that this student is not suicidal or an immediate danger to themselves or others.
Today's Date *
Your Name *
Your answer
Your Email *
Your answer
Student Name *
Your answer
Student Grade *
Relationship to Student *
Select one or more reasons for this referral *
Please provide any other relevant information that would help us best serve the student. Student strengths/assets are very helpful!
Your answer
Is the student aware of the referral? *
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