RMS Mental Health Referral 2025-2026

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Please complete the form below to initiate a Mental Health referral

*** IF THIS IS AN URGENT REFERRAL, SUCH AS SUICIDAL THOUGHTS OR CONCERNS ABOUT SAFETY, please notify your administrator immediately and/or CALL 9-1-1.

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Complete el formulario para iniciar una solicitud de servicios de salud mental.

***SI ESTA ES UNA REFERENCIA URGENTE, COMO PENSAMIENTOS DE SUICIDIO O PREOCUPACIONES SOBRE LA SEGURIDAD, Por favor notifique a su administrador inmediatamente y/o LLAME AL 9-1-1

Email *

Record my email address with my response

Person making the referral *

School Staff

Parent/Caregiver

Student/Self-Referral

Name of the person making the referral *

Student's Name *

Grade *

Primary Concern

Mental Health/Social-Emotional (e.g. symptoms of anxiety, grief/loss, sadness/crying, low self-esteem)

Behavior Issue (e.g. aggressive behavior, defiance, impulsivity, acting out)

Please specify where the symptoms of mental health/ Social-emotional concerns are taking place: *

Home

School

Both at home and school

Description of the mental health/social-emotional concern:

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