Staff Referral Form 2018-2019: Jared Voelker 7th Grade
This form is for staff members to request services for students. Any information shared in this form is for the use of the school counselor and will NOT be kept in the any cumulative files. If the basis for your referral is to report any abuse, neglect, or intent to harm, you are required to contact the Department of Children's Services at 877-237-0004. Thank you for helping me better serve our students.
Your last name
Your first name
Student's Last Name
Student's First Name
Student's grade (number or letter only. Ex. K or 3)
Reason for referral: Check all that apply
Death of loved one
Threat to Self/Others**
OTHER- Add keyword in next question.
Other reason for referral not listed.
Level of urgency
Priority 1- Immediate attention needed- I am also informing an administrator to ensure immediate action.
Priority 2- Attention is warranted in the next few days.
Priority 3- Please add this student to your list of students to see.
Priority 4- FYI- For Your Information
Brief description of issue:
Addition Helpful Information: Please answer as many as possible. Your answers will help me address the student's issues more comprehensively.
Caregiver Information: Student lives with
Have you spoken to the caregiver about this situation?
Yes- If yes, please comment briefly in following question.
Caregiver contact comments:
Has the caregiver requested that I meet with the student?
Please note any interventions or strategies you have tried prior to referring:
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