Churchill High School: HOOTS Referral Form
Students, Parent/Guardian, CHS Staff can complete this form to recommend a student be seen by HOOTS (Helping Out Our Teens in Schools) representatives. The information included in this form is only viewable by HOOTS practitioners, the School Psychologist, the School Nurse, and the CHS Counseling team. All information, including the identity of the submitter, will be kept strictly confidential unless you indicate otherwise. You are also invited to call HOOTS directly at 541-246-2342 or email hoots@whitebirdclinic.org. 
                                                   For EMERGENCIES, call 911 immediately. 
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Email *
Today's Date *
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YYYY
What is your relationship to the student being referred? *
Required
Last name of student being referred to HOOTS *
Please enter the last name of the student as it appears in Synergy.
First name of student being referred to HOOTS *
Preferred Name
Please enter the name the student wants to be called, if different from above.
Pronouns (if known)
Things you may want to talk about or the reason for the referral. *
Submit
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