Academy Wellness Program Student Referral Form
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.
About the student:
Student First Name
Student Last Name
Name of Academic Counselor
Olivia Leung, 9th and 10th Grades
Gladys Dalmau 11th and 12th
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.
Health Concerns/Medical Needs
Sexual or gender Identity
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.
What are the student's strengths and interests that you know of?
Can Express Needs
Connected to club(s)/ sport(s)/outside activities
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?
Discussed concerns with student privately
Offered academic support/ tutoring
Referral to Academic Counselor
Spoke with parent(s)/ guardian(s)
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This form was created inside of San Francisco Unified School District.