Mental Health Team Referral
This form should be completed to refer a student for mental health services (Kelly Larson - School Social Worker, Hailey Gunderson - School Counselor). Please fill out as mush as possible. Thanks!
Email address
Who is making the referral?
Required
Name of person making the referral
Your answer
Relationship to student
Your answer
Student's name (first and last)
Your answer
Student's grade (students in grades K-1 and Mrs. Hirst's classroom will be referred to Hailey Gunderson, students in grades 2-8 will be referred to Kelly Larson)
Required
Current classroom teacher's name
Your answer
Parent/guardian first and last name(s)
Your answer
Parent/guardian phone number and email address
Your answer
What metal health concerns are you noticing with the student?
Required
When are you noticing these behaviors (triggers)?
Your answer
How often are you noticing these behaviors?
Your answer
Have you tried any interventions already? If so, what?
Your answer
Have you or any other teachers/staff members contacted parents first?
Your answer
What would you hope to achieve from referring this student?
Your answer
When is the best time(s) to take the student during the school day?
Your answer
Any other information you think we should know?
Your answer
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