Perspectives Social Emotional Support Referral

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Please fill out all questions to the best of your abilities. A social emotional specialist will follow up within 48 hours.

Please note, this form is not to be used for emergency situations. If there is an immediate mental health emergency, please contact 911.

Email *

Record my email address with my response

Your name *

Relationship to Student *

Parent/Guardian

Teacher

Staff member

Myself

Other:

Student Name *

Which campus does the student attend? *

Perspectives Leadership Academy

Perspectives High School of Technology

Perspectives Rodney D. Joslin

Perspectives Math and Science Academy

Perspectives Middle Academy

Student Grade *

Does the student have an IEP/504?

Yes

Clear selection

Reason for Referral (check all that apply) *

Academic concerns/motivation

Classroom behavior

Aggression/anger management

Bullying

Mental health concerns (depression, anxiety, etc.)

Hygiene

Coping skills

Grief/loss

Family issues

Peer issues

Staff-student issues

Social skills

Executive functioning

Attendance/Truancy

Required

Please elaborate on above responses and how you became aware of situation or how it plays out in the classroom *

Level of need *

Moderate (sometime this week)

Check in

Classroom observation

Social/Emotional (check all areas of concern that apply) *

Self awareness (recognizes one's emotions and thoughts and their influence on behavior)

Social awareness (take the perspective of and empathize with others from diverse backgrounds and cultures, to understand social and ethical norms for behavior, and to recognize school, family and community resources and supports)

Self management (regulate one's emotions, thoughts, and behaviors effectively in different situations)

Decision making (make constructive and respectful choices about personal behavior and social interactions based on consideration of ethical standards, safety concerns, social norms, the realistic evaluation of consequences of various actions, and the well-being of self and others)

Interpersonal skills (establish and maintain healthy and rewarding relationships with diverse individuals and groups)

Required

Please elaborate on above responses and how you see this play out in the classroom *

Please describe any other interventions or strategies you have tried with the student *

Is there anything else you would like to share?

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