If it appears that the situation you are concerned about
is an EMERGENCY.
Please call 9-1-1
The National Suicide Hotline
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.
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 *
Friend of Family
School Support Staff
Community Program Staff (e.g. Hayward Sports Center)
Coach (School sport)
Coach (Community sports)
Your phone # (we may need to contact you for additional information) *
Best time to reach you?
Area(s) of Concern *
Behaviors that you're concerned about. (please check all that apply) This child... *
was exposed to community violence or other trauma
has nightmares or intrusive thoughts
is anxious or fearful
is jumpy or easily startled
avoids reminders of trauma
engages in sexualized play or behavior
has difficulty concentrating
is sad, depressed or irritable
is hopeless or has a negative view of the future
has low self esteem or makes negative self statements
appears to have an eating disorder (e.g. anorexia, bulimia)
is injuring himself/herself i.e. cutting, burning, pulling hair, etc.
has a change in sleep patterns or appetite
is no longer interested in activities
has low or decreased motivation
can't sit still or moves constantly
interrupts and blurts out responses
is inattentive, distractible or forgetful
is disorganized and/or makes careless mistakes
is angry towards others or blames others
is getting into fights or being aggressive
is argumentative and defiant
has difficulty sleeping
is restless or on edge
has specific fears or phobias
displays clingy behavior
is using or abusing drugs or alcohol
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
Send me a copy of my responses.
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