2025-2026 Mental Health Team Referral (Lafayette County)

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Please complete this form for the student's that you feel would benefit from support from our Mental Health Team. Please send me an email at jessica.dearinger@swaec.org if you have any questions. Thank you!

Email *

Name of person completing form *

Phone number of person completing form *

Email address of person completing form *

Student First and Last Name *

Student's Guardian's Name (First and Last) *

Student's Guardian's Phone Number *

Student's Campus *

Student's Grade *

Has Guardian been contacted about student referral? *

Yes

Unsure

Guardian is person submitting referral

Does student already receive mental health services from another provider? *

Yes

Unknown

Services requested for student

School Based Mental Health (In-Person support)

E-Therapy Referral (Virtual Therapy Services)

Other:

Reason for referral *

Feeling sad, down or crying often

No longer finding joy in activities or hobbies that they used to enjoy

Acting paranoid, suspicious, or out of touch with reality

An increase in yelling, feeling angry, or aggressive behaviors

Not wanting to spend time with family or friends, isolating themselves

Difficulty focusing, trouble paying attention, restlessness, hyperactivity or inability to stay on task

A change in appearance such as not caring how they look, not taking care of themselves or their hygiene

Worrying often, especially about things that are out of their control

A change in school performance, such as missing assignments, lower grades, skipping class or showing up late

Feeling really tired or sleeping excessively at home or at school

A change in appetite or weight

Difficulty coping with an event in their life

Difficulty making friends, reported as a "bully" or reports being bullied

Other:

Required

Thank you for your referral. Once this completed form is received, a Mental Health Team member will reach out to the student's guardian and continue the referral process. If the guardian is unable to be reached then the Mental Health Team member will reach out to the person who submitted the referral. Do you have any additional questions or concerns?

Send me a copy of my responses.

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