2019-20 Ida B. Wells Wellness Program Student Referral Form for School Closure.

Thank you for your ongoing support of our students and for making a Wellness referral. Please inform students and families that we will do our best to contact them in a timely manner, and to expect a call from an unknown number.

If a student is expressing thoughts of suicide or another urgent safety concern, please contact their caregiver immediately and/or call 911. Then follow up with Wellness so that we can continue to support the student and family.

Services offered through Wellness remain confidential. Therefore, information can only be shared within the guidelines of the Wellness Initiative's Privacy Policy. Thank you for all that you do!

With deep appreciation,
Ida B. Wells Wellness Team
Your Name, Relationship to Student, and Contact Information *
Name of Student and Contact Information *
Does student know about referral? *
Reason for Referral? *
Mark all that apply. Please elaborate in the details section of this form.
Pertinent Information
Brief details about concerns are helpful.
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