Social Emotional Support Referral
This is not intended to be a Crisis Hotline or a substitute for mental health services. If you are experiencing a mental health emergency, please call 911. If you are feeling suicidal, please call the National Suicide & Crisis Lifeline at 988.

STUDENT:
-- If you need help, and it is not a life threatening emergency, fill out this form. 

-- If you have thoughts of suicide immediately call the Suicide Prevention Hotline at 988 or the Crisis Text Line by texting 988. Assistance is available via text 24/7. Additional information can be found at crisistextline.org. If you have called the hotline or textline due to thoughts of suicide, please provide us with your name and number through the referral form so we can follow up.

REMEMBER: Talk to your parents/guardians, teacher, counselor, school social worker, school psychologist or principal. Help will be provided as your well-being is our priority.

PARENTS / GUARDIANS / CAREGIVERS:
-- If you are concerned about your student's social emotional well-being, please complete the referral form below.
-- If this is an emergency, please call 911 or take your student to the nearest hospital. Fill out the referral form so we are notified that your student is being transported to the hospital.

Referrals are confidential and are forwarded by email to each site Support Services team. 
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Student Name *
Student ID
Person making referral
Clear selection
Your Name *
Your Contact Phone Number *
Please describe what the student is experiencing.
Please check all that apply *
Required
If you selected Other on previous question, please describe below:
Do you have a history of mental health treatment? Or are you currently receiving mental health treatment? If so, through what agency?
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