*
Required
Referral Form for Student Mental Health and Counseling Support
Student Name
*
required
Date Form Completed
*
required
School Student Attends
*
required
Grade
*
required
Name of Person Making Referral
*
required
Contact # or Email of Person Making Referral
*
required
Contact # or Email of Parent or Guardian
*
required
Do you want the student to know you made a referral?*
Yes
No
Has the student or family asks for information about services?
Yes
No
Has the student or family asks about an appointment to initiate help?
Yes
No
Has the student or family asks for someone to contact them to offer help?
Yes
No
Areas of Concern
Choose Area of Concern
Please Select…
Academic Concerns
Behavioral Concerns
Social Concerns
Emotional Concerns
Other Concerns
Please add any information you think would be helpful.
Please send a confirmation email to the address below: