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Glennwood Counseling Referral
If the presenting concern is a life-threatening emergency, please call 911. Otherwise, please complete the form and the information will be reviewed and responded to accordingly. Responses will not be openly shared.
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Student's Name
*
Your answer
Student's Gender
*
Female
Male
Non-Binary
Prefer not to say
Other:
Required
Teacher's Name
*
Your answer
Name of person making referral (if different from above)
*
Your answer
Email address of person making referral
*
Your answer
Relationship to student
*
Teacher/Staff Member
Community Contact
Other:
Required
Concerns
*
Your answer
Any additional information that would be beneficial...
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