Burton Student Support Services Referral Form

Thank you for taking the time to refer your student for Burton's Student Support Services. This form is streamlined to allow you to submit one or more referrals to the following departments within Burton High School:

1. COUNSELING OFFICE/COLLEGE & CAREER CENTER
2. BEACON CENTER
3. WELLNESS CENTER
4. QUIET TIME

Please submit referrals for disciplinary issues through BASIS.

If you prefer to submit a paper version of this referral form, forms are available in the Burton staff mail room, as well as in each of the department offices listed above.

Most services offered to students by the Burton Student Support Team are confidential by law. Therefore, information can only be shared within the guidelines of Burton's different service providers' privacy policies. We will confirm with the referral source that the referral was received and that student was seen by a service provider as soon as possible and appropriate.

If a student is expressing concerns around suicide, self harm or other urgent safety concern, please contact Vida Sanford, Burton's Wellness Coordinator, immediately at 415-469-4006 or sanfordv@sfusd.edu.

Email address
Name of Referrer
Your answer
Date of Referral
MM
/
DD
/
YYYY
Student's First Name
Your answer
Student's Last Name
Your answer
Gender
Please indicate the student's gender pronoun
Grade
Please indicate your relationship to the student
Does this student know you are referring them for support services?
If no, why not?
Your answer
Student's Strengths
Burton Student Support Services Referral Options
The following sections will allow you to make a referral to one or more of Burton's Student Support Service programs.
Which program would you like to refer this student to first?
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