Independence High School Wellness Program Student Referral Form 2019-20
Thank you for making a referral to the Wellness Center. 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. We will give you feedback after a Wellness Team member meets with the student regarding your concerns.
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
Email address *
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 *
Sex *
Supervising Teacher (ST)
Name of student's ST. If possible and appropriate, please inform the student's ST about this Wellness Referral.
Advisory Teacher
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?
Clear selection
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.
Details *
Brief details about your concerns are helpful. Please feel free to come to the Wellness Center or call us to discuss further.
Student Strengths *
What are the student's strengths and interests that you know of?
Prior Interventions *
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?
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