Parent/Guardian Form Paloma School Social Worker Referral
The purpose of this referral form is to request support for your child to promote their success in the school setting.
School social workers provide services in a school-based setting to help students with their social/emotional needs, while striving to promote and support students’ academic and social success. Examples of school-based social worker services include: group/individual counseling, referral to community resources, student check-ins, etc.
IF THIS MATTER IS URGENT OR A SAFETY CONCERN PLEASE CONTACT OUR ADMINISTRATION DIRECTLY.
Disclaimer: My role as a school social worker is to work with students on a short-term basis to improve their ability to succeed in school and help reduce barriers to their academic success. Therefore, if your child is experiencing challenges that require long-term or intensive treatment, please refer to your primary care physician for a therapy referral or contact your insurance provider for a list of resources. If you do not have insurance, you may obtain resources by contacting 211 (858-300-1211) or the Access and Crisis Line at 1-888-724-7240.
*San Marcos Unified School District (SMUSD) assumes no responsibility for the payment, services rendered, outcome of services, or admission into the referrals and/or resources provided.
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Level of Need (at time of Referral)
Low- "I just have some questions I need assistance with in regards to better serve my child."
Medium- "I believe my child needs services, however there is no immediate need."
High- "I need services for my child as soon as possible."
Has your student experienced any of the following family changes (please check all that apply)?
Parents fighting frequently or intensely
Incarceration of caregiver or family member
Deportation of family member
Grief/ Death of a loved one
None of the above
Reason for Referral (please check at least 1 box)
Academic Performance: Low grades/Achievement, Lack of Motivation, Not Working to Full Potential
Attendance Concerns: Frequent absences, Tardies, Nurse office visits
Avoidance of Contact with Others/Extreme Quietness
Disturbs Class Routine
Erratic Behavior Changes
Inattentive; Distractible, Constantly Off Task
In Need of Resources (medical, clothing, housing)
Irresponsibility, Denying, Blaming
Seeks Constant Attention
Self Injurious Behavior
Struggles to Make Friends
Sudden Outburst (Obscene Language, Fighting, Throwing Objects, etc)
How would you rate the student's ability to interact with peers?
Poor/Negative peer interaction
Strong/Positive peer interactions
How would you rate the student's behavior over the past two weeks?
Behavioral issues are frequent
No behavior issues
How would you rate the student's overall mood during the past two weeks?
Typically negative, I am concerned
To what extent are the concerns affecting this student's ability to succeed in school? (academically, behaviorally, socially, or emotionally)
Student's ability to succeed in school is significantly impacted by concerns
Student is successful in school and concerns do not impact them at school
Is the student receiving any other services?
Any other information you feel is important to note?
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This form was created inside of San Marcos Unified School District.