LoWELLNESS Referral Form
Thank you for making a referral to the Wellness Center.
Thank you for making a referral to the Wellness Center. 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. We will give you feedback after a Wellness team member meets with the student regarding your concerns.

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.

For Academic Concerns: please refer student to the Academic Counselor.
For Behavior or Conduct Concerns: please refer student to the Dean.

If you need to consult before submitting your referral, please visit the Wellness Center in room 118, or call Carol Chao Herring, Wellness Coordinator, at ext. 3020

About the person making this referral:
Referrer's Name and Relationship To Student (and Contact info if desired)
Your answer
About the student
Student's First Name
Your answer
Student's Last Name
Your answer
Student's Reg
(# only, If known)
Your answer
Current Grade
Gender Identity
Is the Student truant?
Please be advised that if a student you refer is truant, it may take us longer to see the student and send you feedback.
Academic Counselor
Name of student's Academic Counselor. If possible and appropriate, please inform the student's Academic Counselor about this Wellness Referral.
Does the student know about the referral?
**If No, is it OK to let the student know that you referred her/ him to Wellness?
Students often report feeling safer if they know where the referral came from. They also report feeling cared for when they find out that an adult in the school has noticed that something is going on with them.
Reason for Referral?
Mark all that apply. Please elaborate in the details section of this form.
Required
Details
Brief details about your concerns are helpful. Please feel free to come to the Wellness Center in room 118, or call Ms. Carol Chao Herring, Wellness Coordinator, at ext. 3020 to discuss further.
Your answer
Student Strengths
What are the student's strengths and interests that you know of?
Required
Actions Taken to Support Student
Please describe any efforts taken to support the student with this issue. Have you referred this student for other services? If so, which services or to whom? How did the student respond?
Required
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