EPHS Parent Counseling Referral Form: 2024-2025
If a crisis at home, (Suicidal ideation, concern of harming self or others) instead of filling out this form please contact 911. 

Please complete this form with as much information as possible as it will help the counseling team better understand the student's needs and help us determine the most appropriate supports for the student.

WARNING SIGNS OF SUICIDAL RISK

  • Hopelessness--expresses no reason for living, no sense of purpose in life

  • Rage, anger, seeking revenge

  • Recklessness or risky behavior, seemingly without thinking

  • Expressions of feeling trapped--like there's no way out

  • Increased alcohol or drug use

  • Withdrawal from friends, family, or society

  • Anxiety, agitation, inability to sleep, or constant sleep

  • Dramatic mood changes

  • often unhappy or sad

  • picked on/bullied by others

  • many somatic complaints such as headaches, stomachaches

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Email *
Student Name  *
Student Grade *
Does the student have an IEP or a 504?
 *
Are you referring the student/family for school counseling or other community resources? *
Required
If for counseling, what is the reason for Referral? (Please give specific information/observations of behaviors, information shared by student, attendance, data, etc).
If for Community Resources, check all that apply
What is the preferred language of the student and family?
Person Making Referral
 *
Required
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