Center Middle School Mental Health Services Referral Form
If you have concerns about a student and would like the support of someone from your school's mental health team, please fill out the form below. Complete the entire form before submitting.

Parents/Guardian: If your concerns involve the student displaying/demonstrating self-harming thoughts or behaviors which you believe need immediate attention, please contact the National Suicide Prevention Lifeline at 1-800-273-8255, your school counselor or social worker, or other appropriate agency, dependant on your comfort level.

CSD staff: If the student is in imminent risk of harm to self, please follow established school-based protocol during school hours. If after hours, please follow the established school-based protocol in addition to attempting to contact parents and contact 911 as appropriate.
Email *
Your last name *
Your first name *
Relationship to the student being referred? *
Student last name
Student first name
Student grade
School? *
Is the student currently receiving mental health services (e.g. outsdie therapy/counseling, medication to support mental health needs, history of in-patient treatment) ? *
If answered yes to last questions, please provide additional information that would help in supporting the student.
Does the student have a health/safety plan?
Clear selection
Does the student have an IEP/504? *
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