School Social Worker - Referral Form
Student First and Last Name
Student ID Number
First and Last Name
Position of Person Referring
Transitional Director or Liaison
What concerns do you have regarding this child that warrant counseling services?
Please check all that apply
Alcohol and Other Drug Abuse (i.e. marijuana, prescription medications, etc.)
Behavior Concerns (i.e. classroom disruption, inappropriate language, fighting, etc.)
Family Concerns (i.e. divorce, separation, homeless, communication, etc.)
Harassment (i.e. bullying, cyber-bullying, dating violence, threats, etc.)
Mood (i.e. anxiety, irritability, anger, sadness, self-esteem, etc.)
Physical Changes (i.e. significant weight gain/loss, muscle increase/loss, eating habits, hygiene, etc.)
Self Harm and/or Suicidal Ideation
Social Skills (i.e. loner, socially awkward, disconnected, etc.)
Suspected Abuse (i.e. sexual, physical, financial, emotional)
Suspected Teen Pregnancy
In greater detail, please explain your primary concern(s).
Send me a copy of my responses.
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