STEAM Mental Health Counseling Self Referral 2019-2020
Your referral matters. * 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*

**PLEASE NOTE PARENTS/GUARDIANS WILL BE CONTACTED FIRST TO RECEIVE PERMISSION TO SPEAK DIRECTLY WITH STUDENTS**
Email address *
Full Name *
Your answer
Student ID #
Your answer
Grade *
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Who are you looking for support for? *
If you are referring another student, what is their name?
Your answer
Please share the reason you are seeking support:
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Please mark all that apply
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