Referral Form
If it appears that the situation you are concerned about
is an EMERGENCY.

Please call 9-1-1

~or~

The National Suicide Hotline
1-800-273-8255

If you truly believe that this situation is not an emergency and that the person you're concerned about can wait several days enter the information below to make a referral.
Email address *
Student Last Name *
Student First Name *
What grade is the student in? *
Your Name *Your name will be received by the District Mental Health Coordinator to be used for follow up. All information is confidential per FERPA requirements and will only be shared on an "educational need to know basis."
Your role * *
Your phone # (we may need to contact you for additional information) * *
Best time to reach you?
Area(s) of Concern * *
Required
Behaviors that you're concerned about. (please check all that apply) This child... * *
Required
Can you describe the most troubling behavior(s)
How often are these behaviors occurring?
How long have these behaviors been going on?
The following questions are not required, but any information you can share will be beneficial in helping the student get the services they need as quickly as possible.
Can you describe the interventions that have been tried previously in school?
Can you describe the interventions that have been tried previously outside of school?
Can you describe the interventions that are currently in place in school?
Can you describe the interventions that are currently in place outside of school?
What do you think will help this child be more successful?
Is there anything else you would like to share?
If you would like an email confirmation that your referral was received, please enter the email address below.
Please share any important contact information you have including email addresses and phone numbers.e.g. parents, case worker, HCSD staff that have knowledge of this student and his/her mental health needs
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