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!
Who is making the referral?
Name of person making the referral
Relationship to student
Student's name (first and last)
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)
Current classroom teacher's name
Parent/guardian first and last name(s)
Parent/guardian phone number and email address
What metal health concerns are you noticing with the student?
Adjustment (to school)
Health (family or self)
When are you noticing these behaviors (triggers)?
How often are you noticing these behaviors?
Have you tried any interventions already? If so, what?
Have you or any other teachers/staff members contacted parents first?
What would you hope to achieve from referring this student?
When is the best time(s) to take the student during the school day?
Any other information you think we should know?
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