2025-26 Wellness Center Counseling Referral for Teachers and Staff

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IMPORTANT: PLEASE READ THE FOLLOWING IMPORTANT COVID-19 UPDATES.

Referrals are reviewed several times a week but NOT daily.

****If you are making a referral that needs immediate attention and the student needs to be seen TODAY (e.g., suicide or harm to other risk assessment), please follow your online referral with a phone call to Maddy Sage x 803 and/or Wellness Center Supervisors, Alisa Crovetti at 510-882-2771 or Sari Sanghvi 415-806-1122 or bring student to the Wellness Center or the Counseling office.****

If you are a teacher referring a student due to concerns about academic disengagement, excessive absences, and/or failure to turn in work consistently, please follow up your referral with an email to the student's guidance counselor to alert the counselor to your concerns.

The Wellness Center makes every effort to avoid waitlists, and, given the increased mental health challenges facing our students, we are increasing these efforts. A therapist will make contact with self-referred students within 24 hours of the referral.

Email *

Name of Student *

Which best describes the primary reason for the referral? *

concerns about anxiety or poor stress management skills

concerns about depression

concerns about social challenges

concerns about family or other environmental stressors

recent loss/grief

suspected or confirmed history of trauma/abuse

substance use concerns

behavioral and/or emotional self-regulation concerns

disordered eating/body image concerns

concerns regarding suicidal ideation

concerns regarding non-suicidal self-injury

Other:

Is this student in compressed math? *

yes

Is this student in compressed world language? *

yes

Is this a student who participates in sports through school(aka a student athlete)?

Yes

Maybe/Unknown

Clear selection

Is this a student who participates in sports outside of school(ie: outside sports club, rec league, etc.)?

Yes

Maybe/Unknown

Clear selection

Is this a student who is currently participating in a sport (inside or outside of school)?

Yes

Maybe/Unknown

Clear selection

If you are a student who is currently playing a sport, which sport do they play?

How many AP and/or honors classes is the student currently enrolled in? *

none

School *

Piedmont Middle School

Piedmont High School

Millennium High School

Other:

Grade in 2025-26

Please rate the urgency of this referral. *

The Wellness Center sometimes receives more referrals that we can assign to interns. Please help us know the best way to triage.

This student needs an immediate visit. PLEASE EMAIL SARI SANGHVI AND ALISA CROVETTI DURING DISTANCE LEARNING. WHEN ON SITE, PLEASE CALL VIKI AT X803 OR BRING STUDENT TO WC.

This student has immediate needs and should be seen within the week. (if you check this option, be sure to tell us why this student should be seen within a week in the description above).

This student is a high priority but could be put on a waiting list.

This student could benefit from counseling but will be okay without it.

Unknown at this time.

Is this a family who could be open to a referral to a private therapist if ongoing counseling services are not immediately available at the WC? *

Yes, a private referral could be a substitute for WC counseling.

No, a private referral likely is not a good solution for this student/family.

Unknown at this time.

Are you referring the student because counseling has been added to his/her IEP? *

Please note that we will not accept IEP based referrals unless the referral has been approved by Dena McManis. Please contact Dena for referral procedures.

yes counseling is on IEP

no counseling is not on IEP

unknown at this time

If you answered "yes" to above question, please indicate weekly minutes required by IEP.

If you answered "yes" to above question, please list the counseling goal(s) and case manager.

Please note that we ask for no more than 2 counseling goals for Wellness Center Interns.

By checking this box, you are confirming that the student is aware of the referral and agrees to try at least one session with a WC counselor. *

Yes student is aware of referral and agreed to meet at least one time with the WC counselor.

Does this student's parent/guardians(s) know you are referring them? *

Yes parent/guardian knows of the referral.

No parent/guardian does not know of the referral.

Unknown at this time

What services would you and/or the student like to see the student receive? *

Please check all that apply; for * items, please bring student to Wellness Center immediately and complete form later

check in with counselor

standard 8 to 12 session Wellness Center service

group counseling

suicide risk assessment*

child abuse assessment*

drug and alcohol assessment

referral to a private therapist

Short-term IEP counseling

Ongoing IEP counseling

Required

Is this student open to a short-term counseling group while he/she/they are on the waitlist?

Yes

Maybe

Clear selection

Name of person completing this form and best contact information *

What is the nature of your relationship with this student? *

Please share a few personality qualities about the student and/or the student's preferences in a therapist (e.g., male identifying, LGBTQ) so that we can best match therapist and client.

Anything else you would like us to know?

A copy of your responses will be emailed to the address you provided.

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