Social-Emotional Support Referral Form for Students

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If you or a friend of yours is in need help, and it is not a life threatening emergency, fill out the referral form below. All referrals will be responded to within 24 hours or the next school day. Referrals are confidential. Only those individuals with a need to know will be informed of the referral. Please remember you can always speak with Melissa Ronneseth (480-744-4572) or Eskesha Clark (480-630-5915) during school hours if needed.

*If you or someone you know is in an immediate suicidal crisis, call 911 immediately. If you have thoughts of suicide or just need to talk, you can call the Suicide Prevention Hotline at 800-273-8255 (Available 24 hours a day, 7 days per week).

ADDITIONAL RESOURCE:
Teen Lifeline is a confidential hotline for teenagers. If you have a problem or just want to talk with another teen who understands, then this is the right place for you! You can call 602-248-TEEN (8336) anytime or text between 3-9 pm.

Email *

Your name or the name of the friend you are referring for support: *

Person Making Referral: *

Self

Friend

Other

Contact Number: *

Please Describe What You/Your Friend Is Experiencing: *

Please Check All That Apply(Click Each Box That Applies)Other: *

Anxiety

Depression

Impulse Control

Behavioral Changes (i.e. drastic changes in behavior or personality)

Eating Disorders

Unexplained Weight Loss

Mood Swings

Intense Feelings for No Reason (ie: overwhelming fear-enough to interfere with daily activities)

Difficulty Concentrating

Physical Symptoms (i.e.: often complain of stomachaches or headaches)

Self-Injurious Behavior (deliberately hurting one self)

Suicidal Thoughts/Feelings

Suicide Attempt

Substance Abuse

Social Isolation

Excessive Sleep

Not Enough Sleep

Poor Hygiene

Physical Aggression

Victim of Name Calling/Insults/Teasing/Cyberbullying

Other

Required

Have you previously been treated for a mental health condition? If yes, what condition and what services have been provided?

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