San Elijo Parent Social Worker Referral Form
The purpose of this referral form is to request support for your child to promote their success in the school setting. Examples of school-based social worker services include: group counseling, individual counseling, referral to community resources, classroom interventions, student check-ins.

Disclaimer: My role as a school social worker is to work with students on a short-term basis to improve their ability to succeed in school and help reduce barriers to their academic success. Therefore, if you have concerns that are affecting your child outside of the school environment or your child is experiencing challenges that require long-term or intensive treatment, please refer to your primary care physician for a therapy referral or contact your insurance provider for a list of resources. If you do not have insurance, you may obtain resources by contacting 211 (858-300-1211) or the Access and Crisis Line at 1-888-724-7240.

Please note that I am part time social worker at this school site and will respond within a week of the submission. If this is an urgent matter please contact administration directly.

Upon submission of referral, you will be contacted for additional information and determination for eligibility of school-based services.

Student Name *
Your answer
Student's teacher *
Your answer
Grade *
Parent/Guardian Name, Phone #, and e-mail address *
Your answer
Reason for Referral *
Required
Brief description of reason referral is being made at this time *
Your answer
Is the student receiving any other services? *
Required
How would you rate the student's ability to interact with peers? *
Poor/Negative peer interactions
Strong/Positive peer interactions
How would you rate the student's behavior? *
Behavioral issues are frequent
No behavioral issues
How would you rate the student's overall mood? *
Typically negative/concerning
Typically positive
To what extent are the concerns affecting this student's ability to succeed in school? (academically, behaviorally, socially, or emotionally) *
Student's ability to succeed in school is significantly impacted by concerns
Student is successful in school and concerns do not impact them at school
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