School Health & Wellness Referral Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out this form so a staff member can reach out!

If you are in a crisis, do not complete this form!

The best thing to do if you/a young person is in crisis is to report to the Health Hub/Wellness Center at your school, or go to the school main office! If not at school, you can go to your closest ER if you are concerned about your/a young person's safety!

You can call the 24-Hour Suicide Prevention Hotline anytime 1(855) 587-6373!

PLEASE ONLY FILL OUT THIS FORM FOR NON-CRISIS SITUATIONS!

Para llenar este formulario en español, haga clic en el enlace de abajo.

Formulario de solicitud/remisión en español

Today's Date *

YYYY

I am a... *

Student (request is for me)

Parent or Guardian

School Staff Member

Other:

Required

If you are a staff member and would like us to follow up about this referral, please provide your name and phone number:

Name of student/person who needs our services? *

Phone # of student/person (if known):

Does the student know you are making this referral? *

Yes (also check yes if making this referral for yourself)

What school does the student attend? (if no school, please select other/not in school) *

Analy

Laguna

Guerneville School

Other/Not in school

Please check all areas of concern related to student: *

General Healthcare

Sports Physical

Sexual Healthcare (student must be over the age of 12 to make this type of referral)

Dental care

Counseling or Therapy

Gender and/or Sexuality Related

Resources (like housing, health insurance, food, clothing, etc.)

Drug and/or alcohol use or misuse (including Harm Reduction like Narcan)

Student's parents/caregivers/other siblings/family would benefit from our services as well

Clothing Closet Referral

Other:

Required

Please include comments, details, etc. that might be helpful to us:

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms