Mental Health Counseling Referral Form 20-21
IMPORTANT: If a student you are working with is in crisis or you suspect a student is in danger of self-harm or suicide, call the front office immediately: (408) 723-1839. If school is not in session, call the county Crisis Hotline at 1-855-278-4204 which is open 24 hours a day, every day OR call 911.
Your name (first and last)
Student you are referring (first and last)
Student's grade level
Your title or relationship with the student
Check the behavior(s) that this student is exhibiting and/or the personal issues that concern you. Please check all areas that apply.
Compulsive behaviors (ex. overeating, under eating, stealing, lying, etc.)
Constant health problems
Family problems - please explain in the next question
Poor coping skills
Poor self-esteem/low self confidence
Quarrelsome, uncooperative with teacher/peers
Sad and unhappy
Shy and withdrawn from others
Recent death or other loss
Other - please explain in the next question
Have you spoken to the student about receiving services? (Highly advised so the student is not caught off guard during outreach or scheduling. )
If you have spoken to the student, what was the outcome? Is he/she (or are they) open to receiving services?
Please describe your concern for the student and any relevant information- especially interventions tried, results, and other services the student is receiving.
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