Newmarket School District Social Work Services Referral Form
Conditions for Referring a student for social work services:

-Severe behavior problem
-Significant mental health symptoms
-Failing two or more subjects
-Severe truancy
-Short term crisis (ex. Loss of loved one, recent trauma, divorce etc.)
-Substance use
-Bullying
-Parent referral
-Student referral
-Family challenges impacting student

*Students should have a written pass to come to the social worker’s office outside of
scheduled sessions
*In a crisis, the administration and social worker will be notified
*Staff should always attempt initial interventions to rectify issues before a referral is
made to the school social worker

**To make a referral for social work services, please complete the following form to the best of your ability

Date of Referral *
MM
/
DD
/
YYYY
Name of person making referral *
Your answer
Role of person making referral *
Referral Contact Information (phone number or email) *
Your answer
Student Name *
Your answer
Student Grade *
Student's case manager
Your answer
Is the family aware that a referral is being made? *
Please check all issues that apply to referred FAMILY
Please check all issues that apply to referred STUDENT
Reason for referral *
Your answer
What steps have already been taken/ interventions have you used to alleviate the problem? *
Your answer
Is the student currently being served by other support services? Please explain *
Your answer
Submit
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