Referral Form
If it appears that the situation you are concerned about
is an EMERGENCY.
Please call 9-1-1
~or~
The National Suicide Hotline
1-800-273-8255
If you truly believe that this situation is not an emergency and that the person you're concerned about can wait several days enter the information below to make a referral.
* Required
Email address
*
Your email
Student Last Name
*
Your answer
Student First Name
*
Your answer
What grade is the student in?
*
Your answer
Your Name *Your name will be received by the District Mental Health Coordinator to be used for follow up. All information is confidential per FERPA requirements and will only be shared on an "educational need to know basis."
Your answer
Your role *
*
Teacher
Guidance Counselor
School Administrator
School Nurse
Friend of Family
School Support Staff
Community Program Staff (e.g. Hayward Sports Center)
Police Officer
Coach (School sport)
Clergy
Paraprofessional
Coach (Community sports)
Other:
Your phone # (we may need to contact you for additional information) *
*
Your answer
Best time to reach you?
Your answer
Area(s) of Concern *
*
Academic concerns
Behavioral concerns
Social concerns
Emotional concerns
Physical Health
Family concerns
Other
Required
Behaviors that you're concerned about. (please check all that apply) This child... *
*
was exposed to community violence or other trauma
has nightmares or intrusive thoughts
is anxious or fearful
is jumpy or easily startled
avoids reminders of trauma
is aggressive
engages in sexualized play or behavior
has difficulty concentrating
is sad, depressed or irritable
is hopeless or has a negative view of the future
has low self esteem or makes negative self statements
appears to have an eating disorder (e.g. anorexia, bulimia)
is injuring himself/herself i.e. cutting, burning, pulling hair, etc.
has a change in sleep patterns or appetite
is no longer interested in activities
has low or decreased motivation
talks excessively
can't sit still or moves constantly
interrupts and blurts out responses
is inattentive, distractible or forgetful
is disorganized and/or makes careless mistakes
is angry towards others or blames others
is getting into fights or being aggressive
is argumentative and defiant
worries excessively
has difficulty sleeping
is restless or on edge
has specific fears or phobias
displays clingy behavior
is using or abusing drugs or alcohol
Other:
Required
Can you describe the most troubling behavior(s)
Your answer
How often are these behaviors occurring?
Your answer
How long have these behaviors been going on?
Your answer
The following questions are not required, but any information you can share will be beneficial in helping the student get the services they need as quickly as possible.
Can you describe the interventions that have been tried previously in school?
Your answer
Can you describe the interventions that have been tried previously outside of school?
Your answer
Can you describe the interventions that are currently in place in school?
Your answer
Can you describe the interventions that are currently in place outside of school?
Your answer
What do you think will help this child be more successful?
Your answer
Is there anything else you would like to share?
Your answer
If you would like an email confirmation that your referral was received, please enter the email address below.
Your answer
Please share any important contact information you have including email addresses and phone numbers.e.g. parents, case worker, HCSD staff that have knowledge of this student and his/her mental health needs
Your answer
Send me a copy of my responses.
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