YWLA School Social Worker Request Form
Greetings!

Thank you for making the decision to reach out for support. As a reminder, if you are on campus and are thinking about hurting yourself or if someone is hurting you, inform an adult IMMEDIATELY. If you are off campus and thinking about hurting yourself or if someone is hurting you, call 911 IMMEDIATELY.

To schedule a meeting with me, complete each section below, and I will respond to your request as soon as possible.
 
With Kindness,
Ms. Gash
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*CONFIDENTIALITY DISCLOSURE: Information shared on this form is seen by Ms. Gash and will not be shared with anyone UNLESS you disclose safety concerns (such as you wanting to hurt yourself, someone is hurting you or you want to harm others)
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Who is completing this form? *
If you are a teacher, please type your name in the space below. 
Student's Last Name *
Student's First Name *
Student's ID Number *
Student's grade level *
Required
 Who is your current class period teacher? *
 Who is your next period teacher (if applicable)
Reason for Completing the Form *
Required
Is there anything else you would like to share with me? (Teachers, if this is a BRTI referral, please use the space below to detail your concerns). 
                                                                                  You Matter!
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