2019-20 Ida B. Wells Wellness Program Student Referral Form for School Closure.
Thank you for your ongoing support of our students and for making a Wellness referral. Please inform students and families that we will do our best to contact them in a timely manner, and to expect a call from an unknown number.
If a student is expressing thoughts of suicide or another urgent safety concern, please contact their caregiver immediately and/or call 911. Then follow up with Wellness so that we can continue to support the student and family.
With deep appreciation,
Ida B. Wells Wellness Team
Your Name, Relationship to Student, and Contact Information
Name of Student and Contact Information
Does student know about referral?
Reason for Referral?
Mark all that apply. Please elaborate in the details section of this form.
Student requests general Wellness check in.
Advisor requests Wellness check in for student.
Student/ Family requests support with basic needs and resources.
Student would like to connect with previous Wellness provider.
Student/ Family would like to be connected with School Nurse.
Brief details about concerns are helpful.
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This form was created inside of San Francisco Unified School District.