Mental Health Referral
The Fayetteville-Manlius School District encourages our community to report or self-report any student, faculty, or staff who may be experiencing a personal challenge so that we can provide support to that person. Please note that any referral made via this form will result in outreach by school staff.
THIS FORM IS MONITORED DURING SCHOOL HOURS ONLY.
If someone needs emergency assistance outside of school hours (7:30am-3:30pm), please utilize one of the following resources for support:
- Suicide hotline OR Crisis Counseling OR General Counseling OR Abuse: 315- 251-0600
- Text “Got5” to 741-741 for free confidential 24/7 support
- National suicide prevention hotline: 800-273-TALK
- Dial 211 for help finding local referrals
- Additionally, if you or someone you know is in need of immediate mental health support, please call 911 or 988, the suicide and crisis lifeline.
Please correct the following errors.
Date of Referral:
(MM/DD/YYYY)
Name of the person you are concerned about:
Is this a self-referral?
Yes
No
School the Individual Attends:
F-M High School
Eagle Hill Middle School
Wellwood Middle School
Enders Road Elementary
Fayetteville Elementary School
Mott Road Elementary School
Other (Please specify)
I am concerned about this person experiencing:
Using/abusing illegal substances (vaping, drugs, alcohol)
Self-harm
Anxiety/ Depression
Eating disorder
Grief/Loss
Struggling with gender/sexual identity
Abuse (physical, emotional, etc.)
Other (Please specify)
On a scale of 1-5 (1 being a minor concern and 5 being a significant concern) I believe this concern is...
1(Minor)
2
3
4
5(Significant)
What is your connection to the referral?
Self
Friend
Witness
Parent
Teacher/Staff
Other (Please specify)
How did you learn of this issue?
Self
I was a witness
A student involved told me
Social media/internet
Overheard conversation
Other (Please specify)
You may upload any photographs or screen shots here
Add Attachment
Add Attachment
I understand that this form is not to be used for emergency referrals.
Yes
What would you like to submit?
Question
Comment
Suggestion
Concern
Compliment
Tell us who you are
(Select one or more)
Fayetteville-Manlius Central School District Student
Fayetteville-Manlius Central School District Parent/Guardian
Fayetteville-Manlius Central School District Employee
Community Member
How can we contact you?
Please enter your name and at least one form of contact. If you leave this section blank, you will remain anonymous and we will be unable to follow up with you.
Name
Email
Phone e.g (123) 456-7890
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Required
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