Social-Emotional Support Referral Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Social-Emotional Support Referral Form - Student

Students: If you or a friend of yours is in need of social emotional support, and it is not a life threatening emergency, please complete this referral form.

** If you or someone you know is in an IMMEDIATE SUICIDAL CRISIS, call 911 immediately. If you have thoughts of suicide or just need to talk with someone, please talk to a trusted adult or call the National Suicide Prevention Lifeline at 800-273-8255 (Available 24 hours a day, 7 days per week).

Referrals are CONFIDENTIAL and are forwarded by email to the School Counselors, Psychologist and School Social Worker and will be responded to by the next school day. Only those individuals with a need to know basis will be informed of the referral.
Thank you

Name of person making the referral: *

What grade are you in?: *

Name of the friend you are referring for support or if this is for yourself please state your name: *

Date of Request: *

YYYY

Time

Please describe what you/your friend is experiencing? (What is happening, how long has this been going on, how is the person dealing with it and any additional details) *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of DeRuyter Central School.

Does this form look suspicious? Report

Forms