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Saints Mental Health Referral
*** IF THIS IS AN URGENT REFERRAL, SUCH AS IMMINENT DANGER OR CONCERNS ABOUT SAFETY, PLEASE CALL 9-1-1 OR THE NATIONAL SUICIDE HOTLINE AT 988 IMMEDIATELY***
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* Indicates required question
Name of person submitting referral:
*
Your answer
Preferred method of contact for person submitting referral:
*
Please include your phone number or email so that we can follow up with you!
Your answer
Referred by:
*
Choose
Self
Student on behalf of another student
Teacher
School Staff
Parent/guardian
Student's Name
*
Your answer
Student's Grade
*
9
10
11
12
Mental health concerns
*
Grief or loss
Depression
Anxiety
Bullying
Suicidal ideation or self-harm
Trauma
Eating-related concerns
Stress
Relationship concerns
Substance use
Family concerns/conflict
Other:
Required
Please describe your primary concern and your reason for the referral (be specific):
*
Your answer
Please check this box ONLY if referral requires an urgent response within 24 hours. Otherwise, a mental health specialist will connect with the student within 48 hours.
This referral requires a response within 24 hours
Thank you for asking for help--it is a courageous act, whether for yourself or another! You will be contacted by a mental health support specialist to discuss these mental health concerns. Thank you!
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