Social Emotional/ Behavior Support Referral
If you are worried about a student’s social emotional well-being or mental health fill out this form and a referral will be sent to the appropriate staff member.
If you or someone you know are experiencing emotional distress and in need of immediate crisis counseling, these crisis resources are available 24 hours a day/7 days a week:
National Suicide Prevention Hotline 800-273-8275
Crisis Text Line: Text "HOME" to 741741
Disaster Distress Helpline: 1-800-985-5990 or text "TalkWithUs" to 66746
* Required
Todays date:
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MM
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DD
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YYYY
Student's name:
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Your answer
Date of Birth:
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MM
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DD
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YYYY
Person making the referral
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Classroom Teacher
Other School Staff
Parent/Guardian
Self
Friend
Other:
School:
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Anderson Elementary
Gretchen Higgins Elementary
Tremont Elementary
CA Jacobs/John Knight Middle School
Dixon High School
Maine Prairie High School
Community Day School
Classroom Teacher (for elementary students only)
Your answer
Grade Level
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TK
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Parent/Guardian Name:
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Your answer
Address:
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Your answer
Best Contact Number
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Your answer
Please choose as appropriate:
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IEP
Section 504 Plan
SST
Not Applicable
What are your concerns?
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Your answer
Do your concerns impact student learning? If so, please describe how.
Your answer
Please list positive strengths this student or child displays?
*
Your answer
Any other information that you would like us to know:
Your answer
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