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Wellness Center Referral Form
If experiencing a mental health crisis, DO NOT fill out this form. Please seek immediate help by calling 911 or 988.
Si está atravesando una crisis de salud mental, NO complete este formulario. Busque ayuda de inmediato llamando al 911 o al 988.
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* Indicates required question
Who is the person referring? (Check one)
¿A quién se refiere la persona? (Marque una opción)
Choose
Myself - mí mismo
Peer - compañeros
Teacher - maestra
Administration - administración
Counseling - asesoramiento
Parent or Trusted Adult - familia o adulta de confianza
Student First Name
Nombre del estudiante
*
Your answer
Student Last Name
Apellido del estudiante
*
Your answer
Student ID #
Número de identificación
Your answer
Reason for referral
*
Need a mindful break (art/coloring/fidgets etc.) - necesito un descanso
Academic stress (grades/pressure, etc.) - estrés académico
Stress at home (family conflict, responsibilities, etc.) - estrés en casa
Friend/relationship/social issues - problemas sociales
Mental health (anxiety/stress/grief, etc.) - salud mental
Other:
If "Other," please explain:
Si se "Otro", por favor explique:
Your answer
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