***PLEASE READ: All responses are reviewed and will be addressed/contacted as they are received during school hours. If you are completing this form outside of school hours and are currently experiencing a mental health emergency, please contact 911, or your local mental health authority.
Email (required)
Person completing the form (required) Parent/GuardianStudentNorthland Staff Member
Name of the person completing the form (required)
Student Name (required)
Grade Level of Student (required) Pre-K/Kindergarten/LEAP1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade
Reasons for Referral (choose all that apply) (required) Grief, Loss/DeathSocial skills/FriendsNegative AttitudeWithdrawn/ShyConfidence/Self-EsteemAnxietyDepressionAnger ManagementAdjustment to changeOther
If you chose “Other,” please provide details here
How soon do you (or your student) need to be seen? (required) Right Away!Sometime TodaySometime This Week
