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
Todays date: *
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Student's name: *
Date of Birth: *
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Person making the referral *
School: *
Classroom Teacher (for elementary students only)
Grade Level *
Parent/Guardian Name: *
Address: *
Best Contact Number *
Please choose as appropriate: *
What are your concerns? *
Do your concerns impact student learning? If so, please describe how.
Please list positive strengths this student or child displays? *
Any other information that you would like us to know:
Submit
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