Referral Form
This form is intended to help connect students with a school based  mental health professional. Counselors: Britney Derhak (A-L) and Jill Shulsinger-Wall (M- Z) and ; SEL: Kari Gray
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Email *
Who are you referring? *
Was there anyone else involved? (names here) *
From your perspective, what happened? *
What was your response at the time? What did you try so far? *
When would you like a response by? *
If you find yourself or another in a crisis these resources are available and you are encouraged to use these in addition.
Jefferson Center
1-844-493-8255 or Text TALK to 38255
A local walk-in crisis center is located at Jefferson Center’s Crisis & Recovery Center at
4643 Wadsworth Blvd., Wheat Ridge, CO  80033
https://www.jcmh.org/emergency-crisis-services/

Crisis Textline
Text: 741741
Or Facebook Messenger
https://www.crisistextline.org/

911
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