Student Well-Being Team Referral Form

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Student Well-Being Team Referral Form - Staff

Complete this form to request support from the Student Well Being Team. You should also suggest that families in need of food, financial, health insurance support call 311 or 240-777-0311 to apply for services through Montgomery County such as Care for Kids (insurance), SNAP (food), and FARMs (food). There are currently additional benefits being offered for families who receive each of these services. We ask that ALL families in need of ANY support access this county resource.

If this is an emergency, choose from the options below.

1. File a report with CPS by calling 240-777-4417 and completing this form https://docs.google.com/forms/d/e/1FAIpQLSe6pXB74jsOc_B7yVXLCUgvjLKGbUW9I8S08Kcc88fqV51lYw/viewform.

2. Refer families to Montgomery County's 24/7 Crisis Center. They can call 240-777-4000 or visit the website below for more information.
https://www.montgomerycountymd.gov/HHS-Program/Program.aspx?id=BHCS/BHCS24hrcrisiscenter-p204.html

3. Call 911 or the non-emergency police number 301-279-8000

4. Call the Maryland Safe Schools anonymous tip line 1-833-632-7233

5. Text the Crisis Center at 301-738-2255 to request support navigating the situation

Email *

Student Name (Last, First) *

Student ID Number *

Person Making Referral *

Homeroom Teacher, if different from above (Last, First)

Grade Level *

Pre K

Kindergarten

First

Second

Third

Fourth

Fifth

Names/grade levels of any siblings at Singer

Select the reason(s) for referral *

Wellness (food, clothing, etc)

Crisis Event (make contact with a counselor, school psychologist, or admin via email or phone immediately)

Attendance

Required

Description of student concern *

Date(s) of Absence - Month/Day (if applicable)

I have already connected with the student's caregiver about the concern. *

IMPORTANT REMINDER: Log your communication(s) in the contact log in Synergy.

Yes

Other:

If you selected "No" or "Other" please give details, as appropriate.

What is the best way to contact this family, including language spoken at home and numbers/email needed to make contact? *

Is there anything else we should know?

Demographics *

White

Black/African American

Hispanic/Latinx

Asian

Native Hawaiian/Pacific Islander

American Indian/Alaska Native

EML

Male

Female

Non-Binary

Required

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

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