WJHS Social Work Student Referral Form

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Hello WJHS Students!

If you would like to schedule an appointment with one of your school social workers, please fill out this form to the best of your ability. It is important to fill in your full first and last name so we reach out to the right person. The social workers will do the best they can to meet with you as soon as possible.

This form will be checked during school hours. If you have an urgent concern for someone's safety or your own safety, please contact a trusted adult immediately who can help right away, or call 911.

- WJHS Social Workers

Ms. Kiela (kielan@wilmette39.org)
Ms. Marlas (marlasc@wilmette39.org)
Ms. Panico (panicon@wilmette39.org)

Ms. Higgins (higginse@wilmette39.org)

Email *

Record my email address with my response

Email *

Last Name *

First Name *

Homeroom Teacher *

Would you like to see a social worker because of a concern you have about yourself or someone else? *

Myself

Someone else

How would you rate the concern you have? *

Non-emergency (i.e., I would like to speak with a social worker within a week)

Urgent (i.e., the concern/issue I would like to speak about is urgent and I need to meet with someone ASAP)

Required

Any other information you would like to share?

Send me a copy of my responses.

Submit

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