Social-Emotional Support Referral Form
• If you need help, and it is not a life threatening emergency, fill out the attached referral form. Help will be provided the next school day.
• The Teen Line is open evenings (6-10 pm) at 1-800-852-8336.
• If you have thoughts of suicide immediately call the Suicide Prevention Hotline at 800-273-8255. Please provide us with your name and number so we can follow up.
REMEMBER: Talk to your parents, a favorite teacher, counselor or principal—help will be provided as your well-being is our priority.
• If you are concerned about a student's social emotional well-being, please talk with the school psychologist or counselor and fill out the referral form.
• If you believe that a student is at risk for self-harm, immediately contact your school psychologist and principal and fill out the attached referral form.
• If you are concerned about your child's social emotional well-being, and have been for two weeks or more, please complete the referral form below.
• If this is an emergency, please call 911 or take your child to the nearest hospital. Fill out the referral form so we are notified that your child is being transported to the hospital.
Please remember you can always speak with the principal or call Student Services and Safety at 567-5434.
Referrals are confidential and are forwarded by email to the administrative team in the Student Services and Safety Department. Only those individuals with a need to know will be informed of the referral. All referrals will be responded to within 24 hours or the next school day.
Name of Student:
Person Making Referral:
Date of Request:
Please Describe What You/Your Child Is Experiencing:
Please Check All That Apply
(Click Each Box That Applies)
Behavioral Changes (i.e. drastic changes in behavior or personality)
Unexplained Weight Loss
Intense Feelings for No Reason (ie: overwhelming fear-enough to interfere with daily activities)
Physical Symptoms (ie: often complain of stomach aches or head aches)
Self-Injurious Behavior (deliberately hurting one self)
Not Enough Sleep
Victim of Name Calling/Insults/Teasing
Have you previously been treated for a mental health condition? If yes, what condition and what services have been provided?
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This form was created inside of Natomas Unified School District.