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School-Based Mental Health Support

If you are interested in talking to a Mental Health Worker (Psychological Services or Social Work), please use this form to provide us with your contact information and a member of the team will be in touch as soon as possible.

Please Note: This is not a crisis service. If this is an emergency please call 911.

If you are in need of immediate mental health crisis support please contact:
• Kids Help Phone - 1-800-668-6868
• Distress Centre Durham 905-430-2522 www.centraleasthealthline.ca
• Crisis Intervention Team, Emergency Department – Lakeridge Health Oshawa
• Local Hospital or Family Doctor
• 911 if there is an imminent safety risk.

Student Name:

Parent/Guardian Name:

Parent/Guardian Email Address:

Student Email Address:

Parent/Guardian Phone Number:

Student Phone Number:

School Currently Enrolled:

Grade Currently Enrolled:

Form Completed By:

Student

Parent/Guardian

By submitting this form, I consent to a member of the Mental Health Team (Psychological Services or Social Work) contacting me directly.

YES