Thurgood Marshall High School Wellness Program Student Referral Form
Thank you for making a referral to the Wellness Center. We will give you feedback after a Wellness Team member meets with the student regarding the status of your referral. Please understand that most services offered to students at the Wellness Center are confidential. Therefore, information can only be shared within the guidelines of the Wellness Initiative's Privacy Policy.

Please be advised that if you are a mandated reporter and suspect neglect or abuse, you should contact Child Protective Services directly to consult, and then complete a Wellness referral.

For Academic Concerns Only : please refer student to the Academic Counselor.
For Behavior or Conduct Concerns Only: please refer student to the Dean.

Email address *
About the person making this referral:
Name of Person Making Referral? Or Anonymous? *
Please tell us where to send feedback about this referral. Please include your name, phone and/or email. If Anonymous, we will not be able to provide feedback.
Your answer
About the student:
Student First Name *
Your answer
Student Last Name *
Your answer
Gender Identity *
Grade *
Does the student have an IEP? *
Does the student know about the referral? *
**If No, is it OK to let the student know that you referred them to Wellness?
Is the student truant? *
Please note that it may take us longer to see a student and give you feedback about a student who is often absent.
Is this a substance use/abuse (BIS) referral?
BIS stands for Brief Intervention Sessions and is directed at students who were caught in possession of, or were under the influence of, alcohol or other drugs.
Reason for Referral? *
Mark all that apply. Please elaborate in the details section of this form.
Details *
Brief details about your concerns are helpful. Please feel free to come to the Wellness Center in room 124, or call Olivia Rivera, Wellness Coordinator, at ext 3150 to discuss further.
Your answer
Student Strengths *
What are the student's strengths and interests that you know of?
What is the student's primary language? *
Never submit passwords through Google Forms.
This form was created inside of San Francisco Unified School District. Report Abuse - Terms of Service