2023/24 DHS DSC Referral Form
If this is a life-threatening mental health emergency, please call 988. 

Please be aware that DSC referrals are subject to all mandated reporting laws.
 
Otherwise, please complete the form and the information will be reviewed and responded to accordingly. Responses will not be openly shared unless there is an immediate threat.
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Student Name *
Preferred Name (if different than first name):
Student's Gender *
Student's Ethnicity *
Name of person making recommendation (Who is filling out this form?):
Can we contact you about this referral?
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If it is okay to contact you, please provide us with an email address below.
Relationship to student *
Required
If you checked "not listed here", you can tell us your relationship to this student below:
What would you say this person's PRIMARY presenting concern is? What is the main reason you are making this referral?  *
If you checked "not listed here", you can tell us more about why you are referring this student below:
Do you have another or secondary concern you would like to share as well?
Please use the options below to describe what interventions have already been put in place to support this student. Please check all that apply. *
Required
If you checked "not listed here", you can tell us about other interventions you may have tried with this student below:
How long have you had this concern? *
Any additional information that would be beneficial....
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