Pathways and Keystone: Wellness and Support Services Referral Form 2024-25

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Thank you for using this form to let us know how we can best support you.

This Wellness & Support Services Referral Form form can be used by any Pathways Charter School student, parent/guardian, or staff member in order to request support from the Pathways Charter School team along with Keystone Therapy and Training Services. This support may include phone consultations, parent/guardian or student counseling services, coaching support, staff support, or referrals.

*This referral form is for non-crisis concerns only.*

If you or someone you know is experiencing a crisis, please contact your regional Principal for support immediately. Crisis situations may include but or not limited to panic attacks, severe emotional distress, suicidal ideation, self harm, harm to others, substance use on campus, or suspected child abuse.

You may fill out this form after the crisis has been resolved.

**If this is an emergency, please dial 911 and follow up with your regional Principal.**

Email *

What school site are you connected with (attend or work)? *

Sonoma (Rohnert Park)

Solano-Napa (Vallejo)

Marin (San Rafael)

Required

Who is completing this form? *

Student at (School/Site name)

Parent/Guardian of a Student at (School/Site name)

Staff member at (School/SiteName)

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