Valencia Academy of the Arts Mental Health CARE Referral Form 2020-2021

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*** IF THIS IS AN URGENT REFERRAL, SUCH AS SUICIDAL THOUGHTS OR CONCERNS ABOUT SAFETY, PLEASE CALL 9-1-1 OR THE NATIONAL SUICIDE HOTLINE AT 1 (800) 273-8255 (TALK) IMMEDIATELY***

Email *

Student's Name *

Referred by: *

Student's Grade: *

Best Phone Number To Reach You *

If teacher referral, has the family been informed of your concerns? *

Yes

I am the parent/guardian

Please describe your primary concern about this student and your reason for the referral (be specific): *

Thank you for referring this student. Your feedback is valued. You will receive an invitation to meet with a member of the mental health staff to discuss this student. Thank you!

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