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Wellness Team Referral
2023-2024
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* Indicates required question
Email
*
Your answer
Date
*
MM
/
DD
/
YYYY
Student name
*
Your answer
Grade
*
9th
10th
11th
12th
Person making the referral
*
Your answer
Relationship
*
Choose
Teacher
Counselor
School Social Worker
School Psychologist
Student Assistant Counselor
Nurse
Administrator
Parent
Teacher Assistant (TA)
Child care Worker (CCW)
Student
Other school staff
I would like to refer the above student to the wellness team for the reason(s) identified below. I am concerned about this student's behavior and how it is affecting his/her learning experience and/or the learning experience of others.
Your answer
EMOTIONAL- Check all that apply
Angry Expressions
Consistently Sad
Erratic Mood Swings
Low Energy
Other:
ACADEMIC- Check all that apply
Poor Attendance
Lack of Motivation
Limited Focus
Little or no preperation
Other:
SOCIAL- Check all that apply
Peer relation
Relations with adults
Isolation/withdrawal
Family Relations
Other:
OTHER- Check all that apply
Substance Use
Physical Health
Hygiene
Grief/ loss
Other:
I have observed the following behavior(s).
*
Your answer
I have taken the following actions to address this behavior.
*
Your answer
Please rate the urgency of this request:
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Not Urgent
1
2
3
4
5
6
7
8
9
10
Urgent
I informed this student I was referring him/her to the guidance counselor.
*
Yes
No
Other:
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