Mental Health Referral 23-24
Please complete as much information as possible. We will pull students based on time and severity. If a student is in CRISIS, please do not leave the child unattended. Escort the student, buzz the front office, or radio for the Counselor/SW to come to your room ASAP. You must still complete the referral form as soon as possible. Any referrals done after school hours will be reviewed during school hours. Thank you- Counselor/Social work team!
Email *
Date *
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Student Name *
ID# *
Student's Grade Level *
Referral Initiated By (if you are a student, select "self")
 *
Reason for referral... *
Required
Please offer any other pertinent details you feel may be helpful (e.g., previous contact with guardian, previous behaviors)
Responsive Need... *
Contact Number (if applicable)
Submit
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