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.
This student is not currently suicidal or presenting an immediate danger to themselves or others.
Relationship to Student
Other school staff
Select one or more reasons for this referral
Issues at home
Difficulties with peers
Limited parental involvement
Suspected drug abuse
Suspected mental health concerns
Student is homeless
Lack of basic needs (food, clothing, health services)
Recent change of school/home
Suspected gang affiliation
Poor academic achievement
Disengagement/lack of motivation
Excessive before/after school work hours
Please provide any other relevant information that would help us best serve the student
Is the student aware of the referral?
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