Roseville Adult School: Student Self-Referral Form
Dear Student: PLEASE NOTE - if you or someone you know is in a LIFE-THREATENING SITUATION or experiencing a mental health crisis or emergency, please STOP completing this form and CALL 911 IMMEDIATELY. You can also find Suicide Hotlines and other 24-hour Crisis Intervention help at https://www.suicideispreventable.org or by calling 1-800-273-8255.
Student Name (first and last) *
Your answer
Name of person making this referral (first and last) *
Your answer
I need to talk with you about: *
Required
Something else I want to talk about is:
Optional: Please provide any additional information you'd like to share.
Your answer
Best phone or email to reach me at: *
Please provide a phone number or email where we can contact you.
Your answer
Submit
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