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 *
Sex *
Current Grade *
Does this student have an IEP? *
**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?**
Clear selection
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? *
Required
How have you addressed your concerns with the student? What, if any, prior interventions have been attempted? *
Required
Referral Details *
Brief details about your concerns are helpful. Please feel free to come to the Wellness Center (room 105 or ext.1105) and discuss further.
Student Strengths *
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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