Referral for Additional Support from Counselor

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HELLO INNOVATORS, FAMILIES, AND STAFF!

Please fill out this form if you feel one of our students would benefit from additional support from the counselor.

Looking forward to speaking with you!

FOR EMERGENCIES/CRISES
If you or someone else is having thoughts of suicide, please inform the nearest adult IMMEDIATELY
Life-threatening Emergencies (including suicidal ideation): call 911 or visit the nearest emergency department
Suicide Hotline: 988
Crisis Text Line: Text "Hello" to 741741

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Email *

First and Last Name of Student You are Concerned About

What is your role?

Student

Teacher

Parent

Caretaker

Altro:

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If you are a student and choose to disclose your name please provide your name.

What area can I support with? *

Social Emotional Learning (SEL)

Academic Assistance

College & Career

Altro:

Please provide brief description of what your concern is.

Have any interventions been placed? If so, please describe. *

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