Elementary Counselor Referral

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Please fill out this form and wait for Ms. Llanes to request to see the student.

Email *

Record my email address with my response

Student Name Being Referred *

Date *

YYYY

Is this a student emergency? *

Yes

Is this an outcry of harm to self or others? If so, explain. Contact the counselor or principal immediately. *

Yes, Explain below by 'other'

Other:

Required

Referred By: *

Teacher

Campus Administrator

Other School Based Staff

Parent/Guardian

School Counselor

Student Support Specialist (SSSr)

Paraprofessional or Register Behavior Technician (RBT)

What is the problem or concern? *

Grade Level: *

Pre-K

First

Second

Third

Fourth

Fifth

Sixth

Required

TEACHER or person referring must COMPLETE

Select the INDIVIDUAL(S) who is/are already providing a service(s) to this student: BCBA, SSS, Elementary Counselor OR Dean of Students Secondary Counselor, Other

Board Certified Behavior Analyst (BCBA)/(RBT)

Student Support Specialist (SSSr)

Elementary Counselor OR Dean of Students Secondary Counselor

No services

Other

TEACHER or person referring must COMPLETE

Primary Reason For Referral-Please choose ONE LEVER *

Mental and Behavioral Health and Wellbeing MBHW

Student and Staff Safety SSS

Physical Health Wellness PHW

Supportive Discipline SD

TEACHER or person referring must COMPLETE

Primary reason for referral - Anticipated Need Type - Match to Lever above

MBHW Emotional Wellbeing (anxiety, anger, depression, etc.)

MBHW Social skill deficits (lack social skills to build strong relationships)

MBHW Stress Management (presents unresponsive behaviors/ lack of self regulation)

MBHW Crisis situation (immediate or acute threat to themselves/family/others)

MBHW Substance abuse (student has presented with substance abuse)

MBHW Suicide (student has shown signs of suicide)

MBHW Mental health need (such as trauma/changes in family or grief support)

SSS Physiological safety (doesn't take risks, fear of repercussions)

SSS Physical safety (doesn't feel safe at home or school, etc)

SSS Digital safety

SSS Bullying (intentional, repetitive hurting of person w/imbalance of power)r)

SSS Elopement (running out of room or away without permission)

PHW Basic needs (food/water, clothing, shelter, etc.)

PHW Healthy habits (lack of good hygiene habits, etc)

PHW Coordinating health services (need of services/WIC, dental, vision, hearing, ECI, etc)

PHW Access to wellness (mobile medical units/clinics, wellness checks etc.)

PHW Long term illness

SD Challenging behaviors (tantrums, kicking, outbursts, swearing)

SD Absenteeism (student persistently absent from school or class)

SD Coping skills deficits (lack of appropriate classroom behaviors or social w/peers)

SD Pattern of discipline (three or more incidents in a short amount of time)

SD Need for character building (targeted strategies beyond universal SEL support)

SD Behavior Support Plan (persistent behaviors, targeted interventions, timely monitoring)

SD Need for Behavior Support Team (BCBA, RBT, Sp. ED. SSS, Counselor, etc.)

Clear selection

TEACHER or person referring must COMPLETE

Recommended Services: If necessary, Student Support Specialist referral is a separate form- completed by Counselor

Klarissa Llanes, Elementary Counselor

Board Certified Behavior Analyst (BCBA) and/or Registered Behavior Technician (RBT)

Student Support Specialist (SSSr) Referral- COUNSELOR completes separate form

Outside Services, if selected, provide the recommended agency by selecting 'Other' below

Other

Required

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