CASSY Referral Form
Please use this form to refer yourself or another student to CASSY.
Student's Full Name
If you are referring yourself, please enter your full name. If you are referring another student, please enter their full name.
Type of Referral
What would you (or student you are referring) like to talk to a CASSY therapist about?
Is the parent/guardian aware of the referral
Level Of Urgency
URGENT: student is in IMMEDIATE DANGER due to being actively suicidal or threatening to harm yourself or someone else
Mildly Urgent: student is showing severe symptoms such as severe anxiety or depression, panic attacks, passive suicidal thoughts and/or are experiencing intense emotional distress
Non-Urgent: student is experiencing moderate emotional distress such as anxiety, depression, social, or family problems affecting academic functioning and needs additional support
General Concerns: student is experiencing mild emotional distress and could benefit from some support when available
Informational Only: you would like CASSY to "keep student on our radar"
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This form was created inside of Los Gatos-Saratoga Union High School District.