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.


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.
Email address *
Parent/Guardian Name *
Best number to reach you at *
Students Name *
Students Teacher *
Grade Level *
Level of Need (at time of Referral) *
Has your student experienced any of the following family changes (please check all that apply)? *
Reason for Referral (please check at least 1 box) *
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
Typically positive
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.