Referral Form
If it appears that the situation you are concerned about
is an EMERGENCY.

Please call 9-1-1

~or~

The National Suicide Hotline
1-800-273-8255

If you truly believe that this situation is not an emergency and that the person you're concerned about can wait several days enter the information below to make a referral.
Sign in to Google to save your progress. Learn more
Email *
Student Last Name *
Student First Name *
What grade is the student in? *
Your Name *Your name will be received by the District Mental Health Coordinator to be used for follow up. All information is confidential per FERPA requirements and will only be shared on an "educational need to know basis."
Your role * *
Your phone # (we may need to contact you for additional information) * *
Area(s) of Concern * *
Required
Behaviors that you're concerned about. (please check all that apply) This child... * *
Required
Is there any additional information you can provide regarding the areas of concern?  (for example, has the student had support in-school or out of school for these concerns, how long have you had these concerns? If you are an educator, have you already talked with the student's family about these concerns?) *
Thank you for your assistance in supporting our students!
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Hayward Community Schools.

Does this form look suspicious? Report

Google Forms