JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Request for Mental Health Navigation Support
*Disclaimer - this form should not be used if you or your student is experiencing a crisis. In the event of a crisis, please call 911 or Sauk County's Crisis Line at 1-800-533-5692
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Student First Name
*
Your answer
Student Last Name
*
Your answer
Referral Reason
*
What concerns do you currently have? Examples: self-harm, being aggressive or violent, thinking or talking about suicide, struggling with conflict in the home, isolating or withdrawing from friends/family/interests...
Your answer
Referral Source
*
Parent
Student/Self (please note that parent consent will be needed to initiate services)
Staff
What is the best way to reach you?
*
Your answer
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of School District of Baraboo.
Report Abuse
Forms
