Burton Student Support Services Referral Form
If a student is expressing thoughts about suicide, self harm or other urgent safety concerns, please contact Patrick Mulkern, Burton's Wellness Coordinator, immediately at ext. 1239 or contact the Main Office to notify them of the situation and request that they reach out to Patrick.

BEACON:
Refer students to Beacon for their Teen Center and After School program if you think the student could benefit from healthy social connection with both peers and caring adults, a safe place for students to be after school, or being able to pursue specialized interest. Refer students to Beacon Prevention Services if you think the student could benefit from academic support, interventions to increase motivation, skill development to self-advocate and resolve conflicts appropriately, or employment opportunities when needed.

COUNSELING:
Refer students to the Counseling Office if you think that the student could benefit from support with class placement, credit recovery, college and career services, or academics.

WELLNESS:
Refer students to the Wellness Center if you think the student could benefit from individual or group supports regarding physical, reproductive, or mental health.

Please be advised that you are a mandated reporter and should contact Child Protective Services directly to consult, and complete a Wellness referral, if you suspect neglect or abuse.

Please submit referrals for disciplinary issues through BASIS.

About the person making this referral:
Your Name, Relationship to Student, and Contact Info. *
Your answer
Date of Referral *
MM
/
DD
/
YYYY
About the Student
Student's First Name *
Your answer
Student's Last Name *
Your answer
Gender Identity *
Required
Please indicate the student's pronouns
Grade *
Does this student know you are referring them for support services? *
**If No, why not?
Your answer
**If No, is it OK to let the student know that you referred them to Wellness?
Your answer
Is the student truant? *
Please be advised that it may take us longer to see a student and give you feedback about a student who is often absent.
Student's Strengths *
Required
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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