EmailMeForm
Wellness Team Referral
Please complete the following questions and someone from the PCI wellness team will follow up as soon as possible.
** If this is a medical or psychiatric emergency, please call 911 immediately. **
Name:
Name of person completing this form. (This is optional).
Student Name:
*
Name of the student who needs support.
Your Phone Number:
Please enter your phone number if you would like us to follow up with you.
Contact Information for Student:
*
Please enter a phone number, email, or social media account name for the student who needs support. (You may also enter their teacher name or school site if you know it).
What school does the student attend?
*
Heritage Peak
Rio Valley
Sutter Peak
Valley View
I'm not sure
What resources do you/ the student need help with?
*
Wellness Check
Housing, Food, and Other Resources
I can't get a hold of this student
Other (please complete the next question)
If you checked "Other" above, please describe below what support is needed:
Please upload any supporting documents or screenshots:
Anything else we should we know?
