Dallas ISD - Referral for Mental Health Services

Please complete this form to request to speak with a clinician. NOTE that this form is NOT monitored before or after school hours. Once you submit the form, a therapist will be in touch with you at their earliest convenience.

First Name

Last Name

School Email address You will be contacted by email.

Phone Number Provide your mobile phone number if you have one.

StudentID

Campus

Grade Level

What would you like help with? Select one or more

My Family

My Feelings

Friend

My Choices

Academic

Grief

Other/Private

I understand this is not a crisis line.

If I am under 18, I understand that parent permission is required.

**NOTE** DO NOT use this form for emergencies. If this is an emergency, please talk to an adult you can trust or call the Suicide & Crisis Hotline 988 or go to the nearest emergency room.