JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
STEAM Mental Health CARE Referral Form 2019-2020
*** 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***
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Student's Name
*
Your answer
Referred By (Your Name):
*
Your answer
Student's Grade:
*
Your answer
Best Phone Number To Reach You
*
Your answer
If This Is A Teacher Referral, Has The Family Been Informed Of This Referral?
*
Yes
No
I am the parent/guardian
Please describe your primary concern about this student and your reason for the referral (be specific):
*
Your answer
Thank you for referring this student. Your feedback is valued. You will receive a call from a member of the mental health staff to further discuss this student. Thank you!
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of El Rancho Unified School District.
Report Abuse
Forms