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Parent/Guardian Counseling Referral Form
Latitude offers school counseling services for students. The attached screener is essential in helping us determine the areas in which you are seeking mental health support for your student. Please note that due to clinician caseloads, there may be a wait time and your student may not be immediately seen for non-urgent needs. Your child may also be referred to an outside provider rather than being seen on-site. All referrals our reviewed weekly by our SEL Coordination Team. Please reach out if you have any questions at (951) 741-2990.
If you have urgent concerns regarding a student's immediate safety, including suicidal ideation, please contact an admin or S3 team member directly before submitting this form. The National Suicide Prevention Hotline is also available at 1-800-273-8255.
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* Indicates required question
Email
*
Your email
Parent/Guardian Name
Your answer
Student's Name
Your answer
Date of Referral
MM
/
DD
/
YYYY
Please describe what concerns you have regarding your child.
Your answer
How long has the problem existed?
Your answer
Have there been any significant stressors for the family: losses, births, deaths, moves, hospitalizations, financial problems, in the last several years?
Your answer
What attempts have been made to solve the difficulties.
Your answer
Please check the symptoms that the child is currently experiencing
Sadness or Depression
Suicidal Thoughts
Anxiety and/or Panic Attacks
Acts of Violence and Aggression
Social Isolation and/or Peer Issues
Unusual or Strange Behaviors
Health Condition or Sleeping Problems
Academic Problems
Exposure to Trauma
Memory Problems
Recent Change in Behavior/Personality
Issues with Focusing/Attention
Concerns about their future after graduation/college anxiety
On a scale of 1-5 how concerned are you about your child's well-being or mental health at this time?
Somewhat Concerned
1
2
3
4
5
Extremely Concerned
Clear selection
Does your child know that you are submitting this form/referring them to counseling at school?
*
Yes, we talked about it
No, they are not aware
What is the best way to contact you to follow up about this form with updates or any questions that we have?
Via phone call
Via text message
Via email
Via written letter that is mailed home
Other:
Please provide your current phone number and email address (if applicable).
Your answer
Any other questions, comments, or concerns that you want the team to know about.
Your answer
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