Mental Health Counseling Referral Form

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IMPORTANT: If a student is in crisis and in danger of self-harm or suicide, call the county Crisis Hotline at 1-855-278-4204 which is open 24 hours a day, every day OR call 911.

Email *

Your name (first and last) *

Student you are referring (first and last) *

Student's grade level *

Your title or relationship with the student *

Check the behavior(s) that this student is exhibiting and/or the personal issues that concern you.  Please check all areas that apply. *

Compulsive behaviors (ex. overeating, under eating, stealing, lying, etc.)

Constant health problems

Dating/Sexuality

Discipline problems

Family problems - please explain in the next question

Highly anxious

Low motivation

Persistent absenteeism

Poor coping skills

Poor self-esteem/low self confidence

Quarrelsome, uncooperative with teacher/peers

Sad and unhappy

Shy and withdrawn from others

Unreasonably fearful

Recent death or other loss

Other - please explain in the next question

Required

Students cannot be forced to meet with a therapist, therefore it is necessary to first speak with the student about receiving services. This is an important opportunity to express your care, reasons for concern, and help the student warm up to the idea of getting some hep. If you are not comfortable speaking with the student directly, please reach out to your student's academic counselor so they may understand your concerns and determine appropriate next steps. *

Yes, I understand and have spoken with the student.

What was the outcome of your conversation? Are they open to receiving services? Referred students will be contacted directly to schedule an appointment with a therapist. *

Please describe your concern for the student and any relevant information- especially interventions tried, results, and other services the student is receiving. *

Preference for male or female therapist (if any)? Please explain. *

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