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**
Student ID #
Who are you looking for support for?
Another student at the school
If you are referring another student, what is their name?
Please share the reason you are seeking support:
Please mark all that apply
Sad, depressed or irritable mood
Problems with friends or other students
Problems with family
A recent loss (e.g. break up) or death
Challenges with teachers and other adults in school
Challenges with drugs and/or alcohol
Involvement with law enforcement such as citations, probation or previous incarceration
Housing and/or homelessness issues
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This form was created inside of El Rancho Unified School District.