Independence High School Wellness Program Student Referral Form 2019-20
Please, be advised if a Wellness member or Jennifer Roffle is unavailable for an immediate consultation, that you are a mandated reporter, and should contact Child Protective Services directly to consult at 1-800-856-5553. In addition, please, complete a Wellness referral if you suspect neglect or abuse.
Academic Concerns: please refer student to Jennifer Roffle, School Counselor
Behavior Concerns: please refer student to an Administrator
About the person making this referral:
Your Name, Relationship to Student, and Contact Info.
Please tell us where to send feedback about this referral. Please include your name, phone and/or email.
About the student:
Name of Student
Supervising Teacher (ST)
Name of student's ST. If possible and appropriate, please inform the student's ST about this Wellness Referral.
Name of student's Adviser. If possible and appropriate, please inform the student's Adviser about this Wellness Referral.
Does the student know about the referral?
**If No, is it OK to let the student know that you referred them to Wellness?
On average, how often is the student in school?
Please be advised that it may take us longer to see a student and give you feedback about a student who is often absent.
Reason for Referral?
Mark all that apply. Please elaborate in the details section of this form.
Health Concerns/Medical Needs
Brief details about your concerns are helpful. Please feel free to come to the Wellness Center or call us to discuss further.
What are the student's strengths and interests that you know of?
Have you addressed this issue with the student? If so, how? Have you referred this student for other services? If so, which services or to whom?
Send me a copy of my responses.
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This form was created inside of San Francisco Unified School District.