ࡱ > + - * bjbj " o o E E E E Q e e e e e e g i i i i i i R ~ i e e i ? e e ~ ? ? ? ^ e e g ? g ? ? ? кY.l~ E F ? [ 0 ? ? ? ? ? E E s : REFERRAL FOR MENTAL HEALTH SERVICES Sierra County Mental Health/Drug Alcohol Treatment Services Telephone numbers: Loyalton 530-993-6747 -Downieville: 530-289-3711 School Staff: Please make sure you have a signed release from the parent before you fax this information. Fax To: Sierra County Mental Health at 530-993-6759 If this client is in crisis, please ask a clinician to speak with them as soon as possible! Date:______________________Time of Day:____________________ Student Name:________________________________Home Tel #_______________ Parent or legal guardian name:_____________________________________________ Is it safe to call you here? Yes___No___Alternate number______________________ Students Date of Birth: ___________________ Physical Addresss (Important!!)____________________________________________ MailingAddress_______________________________City______________Zip______ Reason for referral:_____________________________________________________ Suspected or known alcohol/drug use? Has student expressed thoughts of suicide and/or harm to another person? Yes_____No______Please describe: ________________________________________________________________________________________________________________________________________________ # $ % a t ) F v A O n r H 赽襽赽轝 hO/ h9; 5h h9; 5h8 h9; 5h