Independence HS Confidential Self-Referral for Wellness Services 2023

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Independence HS Confidential Self-Referral for Wellness Services 2023 - 24

You can use this form when referring a friend.

First & Last Name *

Pronouns *

Email *

Cell Phone# *

Advisor

Check box if you are you making a referral for a friend?

Referral for friend

Friend's Name & Pronouns

Reason for Referral (please check all that apply):

Emotional Concerns

Physical Health Issues/Questions

Family Concerns

Drugs/Alcohol

Bullying

Peer Relationships Concerns

Romantic Relationship Concerns

Reproductive Health Issues/Questions

Interested in Therapeutic Groups

Other:

I am seeking Wellness services today for myself or a friend because.... *

Thank you for the referral. Either Wellness Coordinator, Dre Collaco, or CHOW, Scott Sweeney, will contact you in 1-2 business days. If you need to contact either one of us please, email us at collacoa@sfusd.edu (Dre) or sweeneys@sfusd.edu (Scott).

USEFUL HOTLINES

Child Crisis Services [mental health]:
415-970-3800

Huckleberry House [safe place to stay]: 415-621-2929

Suicide Prevention Line: 1-800-273-TALK

Crisis Text Line: Text “MYLIFE” to: 741-741

TALK Line for Parents: 415-441-5437

The Trevor Project [LGBTQ]:
CALL: 1 (866) 488-7386
TEXT: 1 (202) 304-1200 (Limited Hours: 12-7pm)

StayWellatHome [tips on coping strategies]:
Sign up by texting, "WELL" to: 415-480-5211
o en español: con la palabra, "BIEN" al: 415-480-5211
Learn about managing stress and improve your mood! Aprende a controlar el estrés y a mejorar tu estado de ánimo!

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