School Counseling Referral Form
Please complete this form letting your school counseling and support staff know how we can support you. Your responses will be kept private. You will receive follow-up communication in the manner indicated by you. We will do our best to reply to you within 2 school days. If you are a student wishing to speak with a counselor, please be aware that parental consent is required for students to receive school counseling. Exceptions: if there is abuse by a family member, if the student is 14 or older, if the student is emancipated.

If you or someone you know is having a mental health crisis or is in danger, please call 911 or a hotline:
Suicide Hotline: 1-800-273-TALK (8255)
Wallowa Valley Center for Wellness Hotline: (541) 398-1175
YouthLine: 1-877-968-8491, or text: teen2teen (839863)
Safe Harbors 24 hour Helpline: (541) 426-6565
Safe Harbors Teen Talk Line: (541) 398-1425

Thank you!
Your name: *
Name of person for whom referral is being made, if not self:
I am seeking support and/or resources for... *
Which of the following would be helpful for your situation: *
Any other details you wish to provide about the type of support that would be helpful:
Preferred manner of follow-up contact: *
If you indicated a follow-up by phone, can we leave a voicemail?
Clear selection
Never submit passwords through Google Forms.
This form was created inside of Joseph Charter School. Report Abuse