Crisis Center Referral Information

INSTRUCTIONS: This form is used by MCPS employees to document student referral information to the Montgomery County Crisis
Center. This form must be attached to MCPS Form 336-32, Authorization for Release/Exchange of Confidential Information and MCPS
Form 270-1, Summary of Parent Conference. Parent/Guardian should hand deliver these forms to the Montgomery County Crisis
Center, 1301 Piccard Drive, First Floor, Rockville, Maryland 20850, Telephone 240-777-4000. Retain one copy for your records.

*Translations below are available for parents/guardians reference.  

Crisis Center Referral Information	89 K	English
Información de Remisión al Centro para Casos de Crisis (Crisis Center)	65 K	Spanish
Information de Référence du Centre de Crise	65 K	French
Thông Tin Giới Thiệu Trung Tâm Khủng Hoảng	121 K	Vietnamese
危機中心推介資訊	240 K	Chinese
응급센터 소견서 정보	181 K	Korean
የከፋ ችግር-ቀውስ ማገገሚያ ማዕከል ማስተላለፊያ መረጃ	88 K	Amharic

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