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Parent and Student Referral for Wellness Services
This form is available to students and parents who have wellness needs and concern. Please fill out this referral to start the process and a member of the Wellness Team will determine the next step.
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* Indicates required question
Email
*
Your email
Student Information: (Name, Age, Grade)
*
Your answer
Best Contact for Student: (Day/Time on campus)
Your answer
School:
*
Choose
Charter College and Career Prep
Charter University Prep
Charter Connections Academy
Charter Home Study Academy
Referral Source
*
Choose
Student (Self-referral)
Parent, Guardian, or other Family Member
Type of Service
*
Wellness Check In
Mental Health Tools
Help with Referral to Mental Health in Community
Social Group
Other:
Required
Reason for Referral
*
Briefly describe the reason for this referral.
Your answer
Safety Concerns Present?
If safety concerns are actively present, contact immediate support.
Call 911, Use crisis text line 741-741, Suicide Prevention Hotline 1-800-273-8255 (or text/call 988)
Form Completed By:
*
Your answer
A copy of your responses will be emailed to the address you provided.
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