School-Based Program Referral Form

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Thanks for reaching out! ✨ Sankofa Counseling staff are located at Cleveland High School for the 2024-25 school year!

Sankofa Counseling offers culturally-specific counseling and is committed to serving Black, Brown, Indigenous, Multi-Racial, People of Color (BIPOC) students.

If you are a student or parent and would like to receive support, please fill out these 'Referral Form' questions and we will get back to you as soon as possible. We will use the information you provide to get in touch with you, or the student, and follow-up about Sankofa's support resources. Please note that completing this form does not guarantee treatment.

Please let us know if you need help with filling out the form! We welcome any questions or additional feedback about how to support students.

💌 Email: info@sankofacounseling.org

🌐 Website: www.sankofacounseling.org
🌱 Insta: @sankofacounseling

📍 Office: 226A & 226R

**This form is HIPAA-compliant & considered secure for the transmission of Protected Health Information (PHI).**

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➡️ ➡️ If you are having a life threatening emergency, please call 911 or go to the nearest hospital Emergency Room (ER). Below are various FREE community support and crisis phone/text lines to contact as needed:

National Suicide Prevention/Crisis LifeLine (confidential emotional support for people in suicidal crisis or emotional distress): Dial #988 988lifeline.org
Multnomah County Crisis Line (24/7): 503-988-4888
Cascadia Urgent Walk-In Clinic (M-F 9AM-9PM) 4212 SE Division St, Suite 100 Portland, 97206 (503)963-2575
**Project Respond - Mobile crisis services are available if you can’t get to
the urgent walk-in Clinic, or are trying to get help for someone else. Call
503-988-4888 for help. Mobile mental health crisis teams may be
accompanied by police (they will generally leave if site is deemed safe for
mental health team). If you are looking for community-based alternatives to
calling the police, visit Don't Call The Police **
Washington County Crisis Line (24/7): 503-291-9111
Clackamas County Crisis Line (24/7): 503-665-8585
(for ages 11-20) YouthLine (24/7): Call 877.968.8491; Text “TEEN2TEEN” to 839863; Chat Online
(for BIPOC) L4L Racial Equity Support Line (weekdays 10AM-7PM): 503.575.3764
(for LGBTQ+) Trevor Life Line line (24/7): 1.866.488.7386, Text “START” to 678678, or chat online
(for LGBTQ+) Trans Life Line, staffed by and for trans+ peers, (10AM - 6PM PST): 877.330.6266
(for Overdose Prevention) Never Use Alone Line (24/7): 877.696.1996
(for Substance Abuse Support) PDX Alcohol and Drug Help Line (24/7): 503.244.1312
(for DV/IPV) Call to Safety (24/7): 1.888.235.5333; Text/Chat (M-F 8AM-6PM) 503.235.5333

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