2020-2021 OC Wellness Referral Spreadsheet
Your Name, Relationship to Student, and Contact Info.
Please tell us where to send feedback about this referral. Please include your name, phone and/or email.
Any important details we should know?
Name of Student
Does this student have an IEP?
I don't know
**If student has an IEP, name of Special Education case manager**
Does the student know about this referral?
**If No, is it OK to let the student know that you referred them to Wellness?**
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.
Reason for Referral?
Health Concerns/Medical Needs
Reflect and Restore Coaching
How have you addressed your concerns with the student? What, if any, prior interventions have been attempted?
One to one private check-in (not in the middle of class)
Allowed cool off time if student is visibly upset, then check private check-in
Practiced active listening and demonstrate empathy
Had a collaborative problem solving conversation with the student
Provided the student a calm or quiet place to sit or talk for 10 minutes (cool down space)
Reached out to parents/caregivers
Tried to gather more information about the community, supports, circumstances of student
Approached student with calmness and compassion
Brief details about your concerns are helpful. Please feel free to come to the Wellness Center (room 105 or ext.1105) and discuss further.
What are the student's strengths and interests that you know of?
Thank you for your referral! A Wellness Center staff member will contact you regarding this referral. For immediate safety concerns, please contact Wellness Coordinator immediately at ext.1105. For immediate nursing concerns, contact 1116
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This form was created inside of San Francisco Unified School District.