School Social Worker (SSW) eReferral: Scandia Elementary 2022-23
Please complete this form if you are requesting support for a student from the School Social Worker (SSW). Your contact information will be required to submit this request. This form will be sent to the School Social Worker and the Principal. All information submitted will be confidential with exception of a duty to warn when a student is a threat to self, a threat to others, or abuse and neglect have been disclosed.

NOTE: Per California Family Code § 6924, any referral for a student younger than 12 years of age will require an Informed Consent be signed by the parent or guardian before services can be established. If possible, consult with the parent/caregiver prior to completing this form to expedite the referral process. Verbal consent is not accepted and a written consent declining services is requested when SSW services have been declined.

Referrals are reviewed each Wednesday unless "High" priority is indicated at the bottom of this form. 

Students in crisis or experiencing a mental or medical emergency should contact emergency services and/or call 911 immediately.

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Email *
Who is this referral for? (student's first and last name) *
Rate the urgency of this eReferral (NOTE: Emergency concerns should be directed to Emergency Services) *
Today's Date *
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Time
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What is your first and last name? *
What is your relationship to the student? *
Grade Level *
Required
Does the student know you are referring them? *
Do the parent(s)/caregiver(s) know you are referring the student?
NOTE: SSW is not allowed to work with any student without the expressed consent from the parent/caregiver. 
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Does Student Receive Special Education Services? *
Does student have a 504 Plan? *
Is the student part of a military family? *
Why is this student being referred? Details can be included on the next question. (Check all that apply) *
Required
Please provide details on your concern(s) *
Does this student receive services outside of school? (Check all that apply) *
Required
What has already been done to help with this specific problem? (Check all that apply) *
Required
Please explain the intervention(s) that you checked above, how long they were used, and what were the outcomes of using them. *
Please identify the greatest need that you feel needs to be addressed first and then explain what you feel would be helpful and/or what type of support you would like for the student. 

NOTE: It is acceptable to write "I am not sure what the student needs", but please still identify what the primary concern is so the student's needs can be prioritized. 
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