This referral form documents a student being referred to a HOPE Squad for help and the follow up steps taken. It collects the name of the referring HOPE Squad member, student in need of help, and date of referral, along with comments on why help is needed. The other side is for the counselor/advisor and includes steps to meet with the student, contact parents, fill out an incident form if a suicidal threat or attempt, and space for additional notes.

1. Referral Form
HOPE Squad member name __________________________
Name of student who needs help _______________________
Date of referral ______________________________________
Comments:
(please document why you believe they need help)
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This side for counselor/advisor only:
Follow up
Step 1: Adult meets with student
Adult name & date __________________________________
Step 2: Contact parents
Comments: _________________________________________
Step 3: Incident form completed on
HOPE4Utah link (only if suicidal threat or attempt)
Date filled out _________________________________
Step 4: Other
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