Social Worker Referral Form

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Please complete this form to refer Beach Elementary students to see the school social worker for counseling.

Email *

Is this an emergency? *

If yes, please contact building administrator or Kathryn Forbes immediately and complete this form afterwards.

Yes

Name of Student: *

Name of Student's Classroom Teacher: *

Person Referring Student for Counseling Services *

Please check all that apply

Classroom Teacher

Parent or Guardian

Principal

Student

Support Staff

Other:

Does the student's parent(s) or guardian(s) know that your are referring him or her for counseling services? * *

PLEASE ensure that parent(s) or guardian(s) know that their child is being referred to the school social worker prior to making your referral unless the situation is suspected to involve abuse and/or neglect.

Yes

Parent Requested Counseling Services

Other:

Reason(s) for Referral * *

Please check all that apply and include specifics in the following section.

Divorce

Changes within the family setting

Abuse or Neglect (suspected or confirmed)

Grief / Death of a Loved One

Anger / Aggression

Anxiety

Difficulty with Friendships / Peer Relations

Academics

Behavior

Self-Esteem

Depression

Social-Emotional Support

Other:

Required

Referral Specifics *

Please provide additional information that you believe will help to fully address this student's needs.

Submit

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