Student Wellness/Mental Health Referral Form
Referral to Student Wellness Counselor for mental health support/coordination
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Email *
Student Name *
Student Email *
Student attends: *
Student Center Region Location *
Who is making this referral? *
Required
Name of and best contact method of person making referral *
Guardian/Custodian Name and contact information (phone and email if available) *
Grade level of student *
Reason(s) for referral *
Required
Please indicate if any of the following applies
Other Pertinent Information
Is parent/guardian aware of referral? *Please note that in the state of Oregon, those age 14 and older can refer for mental health services without parent involvement/notification. *
Other
A copy of your responses will be emailed to the address you provided.
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