Student Referral to meet w/ Miss Daylan 
Any student referred will be met with individually to discuss how to best meet their needs.
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Students Name 
Alcohol and Drug Prevention 
This referral can be either students who are at a higher risk for using or are already using. Please specify which kind of referral it is.

Children of Alcoholics or Other Substance Abusers
Students who have parents or guardians who deal with some sort of alcohol/substance abuse.
Nicotine Use (Vaping)
Students who regularly use nicotine, are at high risk to begin using nicotine (if they are beginning to hang out with other students who use regularly) or are wanting to quit using nicotine. Please specify which category you think the student falls under. 
Anxiety and Depression 
Students that are struggling with symptoms of depression and/or anxiety. 
Depression symptoms may include: sleeping in class, insomnia, feeling sad often or upon waking, not wanting to hang out with friends, suicidal ideation or discussions, hygiene issues, difficulties focusing, lack of motivation, etc. 
Anxiety symptoms may include: anxious, stomachache, headache, racing heart, panic feelings, nausea, ruminating thoughts, withdrawal, avoidance of social interactions, not connecting with others, difficulties focusing, expresses sensory overload or feelings of being overwhelmed. 
Anger Management 
Students who struggle with anger outbursts and/or students who obviously lack emotional regulation or coping skills when they become challenged, frustrated, or angry. 
Social Skills
Students who may struggle socially, whether it be picking up on social ques, struggling to make friends, etc. Please specify. 
Other Referrals
This section is for any other student referrals that you may have. Please give a brief description as to why you are referring the student.
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