Academy Wellness Program Student Referral Form
Thank you for making a referral to the Wellness Center. We will give you feedback after a Wellness Team member meets with the student regarding the status of your referral. 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.

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. 415-558-2650

For Academic Concerns Only : please refer student to the Academic Counselor.
For Behavior or Conduct Concerns Only: please refer student to the Academic Counselor or Dean.
Referral Source Name, Relationship to Student, and Contact Info. *
Please tell us where to send feedback about this referral. Please include your name, title, and email.
Your answer
About the student:
Student First Name *
Your answer
Student Last Name *
Your answer
Pronouns *
Grade *
Name of Academic Counselor
Does the student have an IEP? *
Does the student know about the referral? *
**If No, is it OK to let the student know that you referred them to Wellness?
Does the student have attendance issues? *
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.
Details *
Brief details about your concerns are helpful. Please feel free to come to the Wellness Center in room 125, or call Briana, Wellness Coordinator, at ext.1125 to discuss further.
Your answer
Student Strengths *
What are the student's strengths and interests that you know of?
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?
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