2018-2019 CWMS Counselor Referral
Fill out this form to be referred to the school counselor. Please note the informed consent policy on p. 14 of the student agenda. The counselor will receive an email notification after every submission, but email is not checked regularly after school hours. If you are experiencing a mental health emergency, please call Daymark Recovery's 24-Hour Crisis Hotline at 866-275-9552, the National Suicide Prevention Lifeline at 800-273-8255, or 911.
Name of student being referred
Grade of student being referred
Person submitting referral
Relationship to the person being referred
Please check all that apply regarding this student.
Aggression or Violence
Anxiety or Fearfulness
Being bullied by others
Frequent absences or tardies
Incarceration of family member
Suspected abuse and/or neglect
Suspected drug use
Reason for referring this student
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