24-25 Mental Health Referral Form

Please complete this form after meeting with any student reporting suicide-related or any other mental health concerns. Referrals can come from Hope Squad members and non-members (i.e., any student, staff, parent, etc.).

We strongly encourage you to share this form with anyone in your school who frequently meets with and/or has good rapport with students, even if they are not a Hope Squad advisor. This information helps us keep track of the concerns your school or district is experiencing.

Your school's data is available upon request. The more data you enter, the more information available to you! Please contact the Director of Research, Ashley Taeckens, at ashley@hopesquad.com to request your data or with any related questions.

We are here to support you. Thank you for helping us with Hope Squad research!

Question Title

* What is your role at the school?

Mental Health Therapist (i.e., external agency)

Other School Staff (e.g., Administrator, Classroom Assistant, Librarian, SRO, etc.)

School Counselor (e.g., Crisis Counselor, School Psychologist, LSSP, SEL Specialist, etc.)

School Social Worker (e.g., MTSS Specialist, MHMR Navigator, Community Support Staff, etc.)

Student

Teacher

Parent

Other (please specify)

Question Title

* School Name

Question Title

* Which state / Where is your school located?

Question Title

* Student's grade

Question Title

* Student's gender identity

Male

Female

Transgender male

Transgender female

Non-binary / Gender-fluid

Unknown / Did not ask

Question Title

* Student's race/ethnicity (select all that apply)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Native Hawaiian or other Pacific Islander

White, Caucasian

Other (please specify)

Question Title

* How was the student referred? (select all that apply)

Crisis line, social media, Internet, app, etc. (please specify under "Other")

Hope Squad Member

Parent

School Software (e.g., Gaggle, GoGuardian, Navigate 360, etc.)

Self-referral

Staff

Student referral (non-Hope Squad member)

Teacher

Other (please specify)