Counseling and Student Support Request Form

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Please complete this request for assistance form below to initiate a referral regarding a concern about a student's behavior, and/or mental health/social-emotional progress/functioning and how it may impact academics.

Please Note: Completing this form does NOT guarantee services, but will initiate an evaluation by the Tier 2/3 team and school site admin to review and provide the most appropriate form of support for the student

*** IF THIS IS AN URGENT REFERRAL, SUCH AS SUICIDAL THOUGHTS OR CONCERNS ABOUT SAFETY, please notify your administrator immediately, school mental health team, and/or CALL 9-1-1 OR THE NATIONAL SUICIDE HOTLINE AT 1 (800) 273-8255 (TALK) IMMEDIATELY***

Email *

Record my email address with my response

Student Last Name *

Student First Name *

Student's Date of Birth *

YYYY

School Student Attends *

Grade Level *

Who is Referring? *

Referring Person's Name: *

Referring Person's Phone Number *

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