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Gateway Student Self-Referral
We are here to help! Please complete the following confidential form. A school staff member will be in contact with you soon.
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* Indicates required question
Email
Your answer
Self-Referral for: Student Name (Last, First)
*
Your answer
Student ID Number (If known)
Your answer
Cell Phone Number
Your answer
Referral for:
*
Myself
Another Student
Date
*
MM
/
DD
/
YYYY
Issues (Check all that apply)
*
Drugs and/or Alcohol
Grief & Loss
Divorce
Teen Pregnancy
Teen Issues / Peer Pressure
Family Issues
Anger Management
Gang Activity/Prevention
Coping with Illness
Bullying or Social Media Issues
Anxiety or Depression
Other
Required
In a few sentences please explain what is causing distress and the reason for this referral
*
Your answer
Please rate the severity of needing to be seen by time frame below
*
Need to be seen within 5-10 minutes
OK to be called in anytime during the day
Sometime during the next 24 hours is fine
Required
Thank you for completing the Self-Referral Form. The referred student will be contacted by a Gateway staff member shortly
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