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Ms. Lindsey, District Mental Health Counselor Referral Form
Whether you are a student, caregiver, or teacher, you can fill out this form and I will reach out to you.
This form is confidential.
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* Indicates required question
Email
*
Your email
If you or the student you are referring is in danger or it is an emergency, please call 9-1-1!
Responses will be monitored between the hours of 8:00am-3:30pm Monday-Friday
today's date :
*
MM
/
DD
/
YYYY
Student Name:
*
Your answer
name of person making the referral
*
Your answer
school
*
Rockfield
Natcher
Briarwood
grade
*
pre-K
Kindergarten
1
2
3
4
5
6
teacher
*
Your answer
reason for referral
*
Your answer
How urgent is it?
*
whenever you can
this week
48 hours
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