High School Counseling Referral Form
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This referral will alert the school counselor during regular school hours.  If this is an emergency, please call 911, the Suicide Prevention Helpline (1-800-273-8255 or text "support" to 741-741), or the Child Abuse Hotline (1-800-482-5964).
Student Name *
Last Name *
Grade *
Relation to student *
Your name and contact information (optional but helpful)
Reasons for referral (check all that apply) *
Is there anything else that you would like to share / explain about the situation?
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