Mental Health & Resource Referral
Complete this form to refer a HHS/HMS student/family for support from the School Social Worker, district Family Resource Coordinator/McKinney Vento Liaison or other outside resources. Upon completion of the form, support staff will contact you within a couple school days regarding next steps.

** Please do not tell the family they are eligible for supports until further determination is made after the referral. Support staff will follow up with family regarding next steps**

For more information on the process: https://docs.google.com/drawings/d/13Fkpt3bYeXYRQXlLFTTT3s5ZoXXHXQSBivBXkaHzHlk/edit?usp=sharing
Email address *
Person completing the form *
Your answer
Initial Staff Referring (if different than person completing form)
Your answer
Student First & Last name *
Your answer
Student's Grade *
Are parents aware of the referral? (please do not guarantee support/resources) *
Who has been informed of referral? *
Required
I am referring this student for: *
Required
Student/Family strengths
Your answer
Top TWO areas of concern: *
(include additional helpful information below in the notes)
Required
Supports/Interventions Currently in place (to your knowledge): *
Required
Best time(s) student is available *
Your answer
Notes
Your answer
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