Check in script and referral note

Check in script and referral note

Five minute check in

• "I've noticed ______. I care about how you're doing."
• "How are things going, really?"
• Listen. Don't fix. Let silence sit.
• "Thank you for telling me."
• "Can I walk you to the counselor now?"
• Check in again tomorrow.

If the student talks about dying or hurting themselves

• Stay with the student. Do not leave them alone.
• Walk them to: ______________________ (counselor or administrator)
• Follow our district suicide prevention steps.
• Life in danger right now: call 911.

Note for the counselor (facts only, the student's own words)

• Student name: ______________________ Date and time: __________
• What I noticed: ______________________
• What the student said: ______________________
• Who I told, and when: ______________________

Numbers

• 988 Suicide & Crisis Lifeline: call or text 988
• San Mateo County schools, Crisis Line: (650) 579-0350
• Santa Clara County schools, youth crisis: (800) 704-0900, press 1
• Child abuse: San Mateo (650) 802-7922; Santa Clara (833) 722-5437
• My county's crisis line and child abuse line (other counties): ______________

Keep completed notes private and give them only to the counselor or administrator.

From Teachers Student Distress. Facts checked October 21, 2026. Free information, not legal or medical advice.