Social Worker Referral Form
Thank you for reaching out to your school social worker. Be aware that I do not check email except during school hours. If this is a crisis or emergency call 911 or go to your local emergency room.
Confidentiality- Information students share with the school counselor is confidential. The student’s right to privacy is guarded as much as permitted by law, ethics, and school policy. The school social worker is obligated to break confidentiality when there is potential harm to the student or others, concern of neglect or abuse, or a court of law that requires testimony or student records.
At times, the social worker and school-based staff (teacher, school counselor, principal, etc.) will need to exchange information about your child (how are they coping in class, strategies to help, etc.) All communication will take place only on a need-to-know basis.
E-mail transmissions may contain confidential health information that is privileged and legally protected from disclosure by the Health Insurance Portability and Accountability Act (HIPAA). This information is intended only for the use of the individual or entity named in the email. If you are not the intended recipient, you are hereby notified that reading, disseminating, disclosing, distributing, copying, acting upon or otherwise using the information contained in this e-mail is strictly prohibited.
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Names of siblings?
Best Phone Number (please enter (xxx) xxx-xxxx)
What are your concerns?
Access to technology and internet
My child/children need support
House hold needs
Mental health and counseling
Mentor support for student
I need help:
Finding a therapist/counselor for my child
Getting my student motivated to work from home
Finding resources for food, clothing, etc.
Getting ideas and suggestions on how to support my child
Getting ideas and suggestions on how to help improve my child's behavior at home
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This form was created inside of Knox County Schools.