SHS Wellness Center/School Based Counselor Referral Form
If the student is in crisis, DO NOT fill out this form. Please seek immediate help by calling 911 or referring to the crisis resources listed below.
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Email *
Name of Person Referring Student *
Your Relationship to the Student *
What is the best time for student to receive school based counseling? (optional) *
What is the second best time for student to receive school based counseling? (optional) *
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.
Student's ID Number (if known)
Student's Email (if known)
Has the Student Received School Support before? *
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