No Excuses University @ Durfee Elementary 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***
Email address *
Student's Name *
Your answer
Referred By: *
Your answer
Student's Grade: *
Your answer
Best Phone Number To Reach You *
Your answer
If teacher referral, has the family been informed of your concerns? *
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 an invitation to meet with a member of the mental health staff to discuss this student. Thank you!
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