• Canyon ISD Support Services Referral Form Please enter as much information as possible about the student and family. Once the referral is received we will respond as soon as possible based on the type of referral. If the referral is Emergent please contact us via cell phone and then send the referral form as soon as possible.

• Date*
   - Month  - Day Year

  Date
• Type of Referral*
  Emergent (immediate action needed) Urgent (intervention within 3 calendar days) Routine (intervention within 4 calendar days)
• Referring Professional (Name and Title)*
• Email Address*
• Student Name*
• Guardian Name (guardian MUST be notified prior to making the referral)*
• Street Address*
• Grade*
• Date of Birth*
   - Month  - Day Year

  Date
• City*
• State*
  AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Zip Code*
• Phone Number*
• Student ID #*
• Campus*
• Reason for Referral*
  Family Crisis/Conflict Suicidal Ideations or Threats Behavior Issues Drug/Alcohol Issues Anxiety, Depression and other Mood Issues Threats to Others Cutting/Self Harm Involvement or Possible Involvement with Child Protective Services Jail/Detention
• Tell us more about what is going on:*
• Referring to:*
  Student and Family Advocate Referral Drug and Alcohol Intervention Referral
• Submit Print Form
• Should be Empty: