Galileo Academy Wellness Program Student Referral Form
Thank you for making a referral to the Wellness Center.

Please understand that most services offered to students at the Wellness Center are confidential. Therefore, information can only be shared within the guidelines of the Wellness Initiative's Privacy Policy. We will give you feedback after a Wellness Team member meets with the student regarding your concerns.

The Wellness Center works in partnership with other Student Support Services at Galileo. If you are aware of a support service that the student is already receiving, please make note of that in your referral.

Please be advised that you are a mandated reporter and should contact Child Protective Services directly to consult, and complete a Wellness referral, if you suspect neglect or abuse.

Academic Concerns: please refer student to the school counselor
Behavior Concerns: please refer student to the dean

Timestamp:
**Date Assigned:
**For Wellness Coordinator only.
Your Name, Relationship to Student, and Contact Info.
Your answer
Last Name of Student
Your answer
First Name of Student
Your answer
Grade Level
Gender Identity
Preferred Gender Pronoun
Does the student know about the referral?
**If No, is it OK to let the student know that you referred them to Wellness?
Is the student truant?
Please be advised that it may take us longer to see a student and give you feedback about a student who is often absent.
Reason for Referral?
Mark all that apply. Please elaborate in the details section of this form.
Required
Details
Brief details about your concerns are helpful. Please feel free to come to the Wellness Center in Room 151 or call Sydney Fisher, Wellness Coordinator at x3162 to discuss further details.
Your answer
Student Strengths
What are the student's strengths and interests that you know of?
Your answer
Prior Interventions
Have you addressed this issue with the student? If so, how? Have you referred this student for other services? If so, which services or to whom?
Your answer
Is this a BIS/substance use referral?
Have you addressed this issue with the student? If so, how? Have you referred this student for other services? If so, which services or to whom?
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