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Newhart Student Counseling Referral- Ms. Ruiz
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* Indicates required question
What is your full name?
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Your answer
What grade are you in?
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6
7
8
Class Period
Which class period has the issue been taking place?
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0
1
2
3
4
5
6
Not Applicable
Summary of Concerns
please give specifics of the problem
Your answer
How urgent is this matter?
*
1- the student will be seen within a week 2- the student will be seen as soon as possible 3-the student will be seen immediately
Level One- The student wishes to speak with someone, but it is not an emergency or you notice something is wrong with the student
Level Two- The student wishes to speak with someone and it is an emergency (but not one of the emergencies listed for level 3) or the student is visibly emotionally upset, but they can still remain in class
Level Three-They are so visibly emotionally upset that they cannot remain in class, they are a potential harm to self, harm to others, someone is harming them, or they know of a threat on campus.
Counselors are available to respond Mon-Fri from 8:15-3:45 (except holidays/breaks) . If this is an EMERGENCY and you do not have immediate access to a counselor, please speak to a trusted adult ASAP, call 911, or call the Suicide Prevention Lifeline : 1.800.273.8255.
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