Rivera Middle School Mental Health CARE Referral Form 2021-2022
*** IF THIS IS AN URGENT REFERRAL, SUCH AS SUICIDAL THOUGHTS OR CONCERNS ABOUT SAFETY, PLEASE CALL 9-1-1 OR THE NATIONAL SUICIDE HOTLINE AT 1 (800) 273-8255 (TALK) IMMEDIATELY***
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Email *
Student's Full Name *
Referred By (Your Name): *
Student's Grade: *
Best Phone Number To Reach You *
If This Is A Teacher Referral, Has The Family Been Informed Of This Referral? *
Please describe your primary concern about this student and your reason for the referral (be specific): *
Thank you for referring this student. Your feedback is valued. You will be contacted by a member of the mental health staff to discuss this student. Thank you!
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