Washington High School Wellness Center Student Referral Form 2016-2017
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.

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

For Academic Concerns: please refer student to the Academic Counselor.
For Behavior or Conduct Concerns: please refer student to the Dean.

If you need to consult before submitting your referral, please visit the Wellness Center in room 121, or call Ms. Veronica Garcia, Wellness Coordinator, at ext. 13402

Email address
Referral Source Name, Relationship to Student, and Contact Info.
Please tell us where to send feedback about this referral. Please include your name, phone and/or email.
Your answer
Student First Name
referral
Your answer
Student Last Name
referral
Your answer
Gender Identity
Grade
Name of Academic Counselor
Does the student have an IEP (LEAD student)?
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 note that it may take us longer to see a student and give you feedback about a student who is often absent.
Is this a BIS (Brief Intervention Services)/ substance use referral?
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 121, or call Ms. Veronica Garcia, Wellness Coordinator, at ext. 13402 to discuss further.
Your answer
Student Strengths
What are the student's strengths and interests that you know of?
Required
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?
Required
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