LMFT Referral for Admin/Staff 
 PLEASE STOP AND CONTACT THE COUNSELOR OR ADMIN IMMEDIATELY IF STUDENT IS THREATENING SELF HARM OR HARM TO OTHERS IN ANY WAY AND/OR SAFETY IS AT RISK.  

THIS WILL NOT SERVE AS A CPS REPORT...PLEASE REPORT TO CHILD PROTECTIVE SERVICES IF CHILD ABUSE IS SUSPECTED.
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Student Name: *
Staff Name  *
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Concerns: *
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Has parent been notified?
What interventions have been implemented?  *
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Is student receiving outside services? *
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