Mental Health Counseling Referral Form 20-21
IMPORTANT: If a student you are working with is in crisis or you suspect a student is in danger of self-harm or suicide, call the front office immediately: (408) 723-1839. If school is not in session, call the county Crisis Hotline at 1-855-278-4204 which is open 24 hours a day, every day OR call 911.
Email address *
Your name (first and last) *
Student you are referring (first and last) *
Student's grade level *
Your title or relationship with the student *
Check the behavior(s) that this student is exhibiting and/or the personal issues that concern you. 
Please check all areas that apply. *
Have you spoken to the student about receiving services? (Highly advised so the student is not caught off guard during outreach or scheduling. ) *
If you have spoken to the student, what was the outcome? Is he/she (or are they) open to receiving services?
Please describe your concern for the student and any relevant information- especially interventions tried, results, and other services the student is receiving. *
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