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
or by calling 1-800-273-8255.
Student Name (first and last)
Name of person making this referral (first and last)
I need to talk with you about:
Feeling better about myself
Being unhappy or depressed
Breakup of a relationship
Death/loss of a loved one
Getting along better with my family
Getting along better with friends / peers
Feelings of stress or anxiety
How other people are treating me
Someone I am worried about
Something else I want to talk about is:
Optional: Please provide any additional information you'd like to share.
Best phone or email to reach me at:
Please provide a phone number or email where we can contact you.
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