Crisis Release Form

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					Denver Middle School Academy Crisis Release Form
I, __________________________________________, have been informed by (PRINT Parent/Guardian Name) School Social Worker, that my child, _____________________________________, (PRINT Student Name)

________ Needs psychiatric or clinical attention immediately for suicidal thinking, comments and behavior. And/or ________ Needs to be monitored closely for suicidal behavior. (If behavior continues, I will obtain psychiatric or clinical attention immediately.)

I assume full responsibility for obtaining help for my child. I also release Detroit Edison Public School Academy and their representatives from further responsibility in this matter. I am aware that Protective Services may be contacted regarding this matter, if I do not follow through with the above recommendations.

Parent Signature: _______________________________ School Social Worker: ___________________________ Witnessed by: _________________________________

Date: __________________ Date: ___________________ Date: ___________________

__________ Parent was given signs of suicide and depression list, as well as, a list of resources stating where the child can be taken for crisis evaluation.


				
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