Family/Student Needs Referral Form
Please complete this form to inform the Gloucester High School Family/Student Support Team about students and families who may benefit from additional support at this time. This referral form may be completed by parents, guardians, students, teachers, staff, and concerned community members.
The family will be assigned a case manager who will contact you to develop a plan of support for you and secure necessary resources.
If this is a mental health emergency and you require immediate assistance please call 911 or North Shore Emergency Services: 978-744-1585 or go to your nearest emergency room.
Last Name of Student:
First Name of Student:
Year of Graduation:
Person Completing Form
Contact Information (email/phone)
Student/Family needs support with:
Housing Stability Resources
Financial Stability (Rent, bills, utilities, unemployment)
Mental Health Support for a Parent
Mental Health Support for a Student
HAWC- Domestic Violence Support Service
Online Resources (webinars, parent or student chats, etc)
Weekly Phone Check-Ins
Technology (Chromebook, wifi, other)
Medical/Physical Health Support for a Parent
Medical/Physical Health Support for a Student
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This form was created inside of Gloucester Public Schools.