Social-Emotional Support Referral Form

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STUDENTS:
If you or a friend of yours is in need help, and it is not a life threatening emergency, fill out the referral form below. All referrals will be responded to within 24 hours or the next school day. Referrals are confidential and are forwarded by email to the administrative team in the Student Services & Support Department. Only those individuals with a need to know will be informed of the referral. Please remember you can always speak with the principal at your school or call the Student Services & Support department directly at 916-567-5434.

*If you or someone you know is in an immediate suicidal crisis, call 911 immediately. If you have thoughts of suicide or just need to talk, you can call the Suicide Prevention Hotline at 800-273-8255 (Available 24 hours a day, 7 days per week).

ADDITIONAL RESOURCE:
Teen Line is a confidential hotline for teenagers which operates every evening from 6:00pm to 10:00pm. If you have a problem or just want to talk with another teen who understands, then this is the right place for you! You can call us at 800-TLC-TEEN (852-8336) or text us by texting “TEEN” to 839863.

Email *

Your name or the name of the friend you are referring for support: *

Person Making Referral: *

Self

Friend

Other

Contact Number: *

Date of Request:

YYYY

Time

Please Describe What You/Your Friend Is Experiencing:

Please Check All That Apply

(Click Each Box That Applies)

Anxiety

Behavioral Changes (i.e. drastic changes in behavior or personality)

Difficulty Concentrating

Depression

Excessive Sleep

Eating Disorder

Impulse Control

Intense Feelings for No Reason (ie: overwhelming fear-enough to interfere with daily activities)

LGBTQ+

Mood Swings

Not Enough Sleep

Poor Hygiene

Physical Symptoms (ie: often complain of stomach aches or head aches)

Physical Aggression

Self-Injurious Behavior (deliberately hurting one self)

Suicidal Thoughts/Feelings

Suicide Attempt

Substance Abuse

Social Isolation

Unexplained Weight Loss

Victim of Name Calling/Insults/Teasing

Other:

Have you previously been treated for a mental health condition? If yes, what condition and what services have been provided?

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