Wellness 2020-21 Referral Form

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Thanks for reaching out! Please fill out the form below. Your preferred staff member will reach out to you to schedule an appointment. You will then receive an electronic pass or a meeting link (if virtual). Please provide contact information in the event that a staff member needs to contact you on your non-in-person day.

Name (First and Last) *

Grade *

Required

What Wellness Center Staff member would you like to meet with? *

Ms. Strash

Ms. Mullinax

Ms. Newman

Ms. Gentry (Housing/Resource Specialist)

Any Available Wellness Staff

Other:

Required

Please Describe Concern *

Grief and Loss due to COVID

Worry/Overwhelmed

Family

Relationships

Food/Housing/Resources

Other non-emergency

Don't want to identify on form

Required

What kind of appointment would you like? *

In-person

Virtually

Indicate if you are an in-person or VLA (virtual) learner *

In-person

Virtual Learning Academy

Preferred contact information *

Voice Call: List number in additional information below

Email: List email in additional information below

Schoology message

Other:

Can you identify one trusted adult at school whom you feel connected to? *

Yes

Other:

Additional Information (including contact information) *

Submit

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