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Self/Peer CBMH Referral Form
This form will be submitted to the School’s Pupil Service Team for Triage
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* Indicates required question
Name of Student
*
Your answer
Who is making this referral?
If you are referring a peer and want to share your name, please use the Other... option.
self
Other:
Clear selection
Are you currently seeing a therapist outside of school?
Yes
No
Clear selection
If you do see a therapist, how often do you see them?
1 time per week
Every other week
1 time per month
I see a therapist, but not frequently enough
Other:
Clear selection
Members of the school problem-solving team may reach out to you to gather more information. May we contact you?
*
Yes, it’s ok to contact me about my concern
No, please don’t contact me
What are you noticing about yourself/your peer?
*
Please check all that apply.
Anxious/fearful/worries
Anxiety
Poor attendance/lack of school engagement
Relationship difficulties
Difficulty sleeping
Has experienced loss
Restless/appears to be on edge
Physical aggression
Trauma history
Exposed to recent trauma event
Jumpy/hypervigilant
Nightmares/intrusive thoughts
High risk behavior (weapons, drugs, sexualized behaviors)
Decreased motivation
Depressed/sad/irritable mood
Hopelessness/ negative view of future
Loss of interest in activities student once enjoyed
Self harm
History of suicidal ideation/attempt
Poor self-concept
Angry towards others/blames others
Argumentative
Constantly moving
Defiant
Disorganized
Inattentive/distractible
Interrupts/blurts out responses
Other:
Required
How often do these behaviors occur? (several times per day, once per week, etc)
*
Your answer
What else would you like us to know?
Your answer
Please rate the urgency of this request.
*
Not Urgent
Moderately Urgent
Urgent
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