School Nurse Support Form

If you have a non-emergency issue that you want to discuss with a school nurse please complete the form below. A school nurse will respond to you within three business days.

STUDENTS:

If this is an emergency, please call 911 or have someone take you to the nearest hospital. If you have trouble breathing, have persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, or have bluish lips or face, call 911 or have someone take you to the nearest hospital.

If you need help, and it is not a life threatening emergency, fill out the referral form below. The usual response time from a district nurse is within 3 business days.

If you are currently having thoughts of suicide, immediately tell an adult or call 911. If you are unable to do that, call the Suicide Prevention Hotline at 530-756-5000 or 800-273-8255. After you have received help, please fill out this form so a school staff member can follow up.

24 Hour support is also available: Teen Line 530-753-0797 and Crisis Text Line Text "HOME" to 741741

TEACHERS/STAFF:

If you are concerned about a student's health, fill out the referral form which will be shared with a school nurse.

If you believe that a student is at risk for self-harm, immediately contact your school counselor and principal and fill out the social-emotional referral form.

PARENTS/GUARDIANS:

If this is an emergency, please call 911 or take your child to the nearest hospital. If your child has trouble breathing, has persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, or has bluish lips or face, call 911 or take your child to the nearest hospital.

If you are concerned about your child's health and it is not a life threatening emergency, fill out the referral form below. The usual response time from a district nurse is within 3 business days.

Referrals are confidential and are forwarded by email to the school nurse. Only those individuals with a need to know will be informed of the referral.

The usual response time from a district nurse is within 3 business days.

School Nurse Support Form

Your Full Name
Relationship to Student	Self Parent/Guardian/Family Member Friend Teacher/Staff Member Other
Student Full Name
School
Grade
School Nurse
Phone Number (Include Area Code)
Contact Email
Student’s Medical Diagnosis (if known)
Student’s Current Medication(s) (if known)
Student’s Current Medical Insurance (if known)
Student’s Primary Health Care Provider (if known)
Last Time Seen by Health Care Provider (if known)
What is Your Health Concern?
Additional Comments

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