Mental Health & Resource Referral
Complete this form to refer a HHS/HMS student/family for support from the School Social Worker, district Family Resource Coordinator/McKinney Vento Liaison or other outside resources. Upon completion of the form, support staff will contact you within a couple school days regarding next steps.
** Please do not tell the family they are eligible for supports until further determination is made after the referral. Support staff will follow up with family regarding next steps**
For more information on the process:
Person completing the form
Initial Staff Referring (if different than person completing form)
Student First & Last name
Are parents aware of the referral? (please do not guarantee support/resources)
Who has been informed of referral?
Marsha Edel/Shannon Stenzel
SPED Case manager (if applicable)
No one yet
I am referring this student for:
Individual Mental Health support
Referrals to outside providers (financial, food, county support)
Family Support-Parent Advocacy
Possible Homeless/transtional living arrangement situation
Treatment Center Coordination (Transition in/out)
Food 4 Kids Progam
Top TWO areas of concern:
(include additional helpful information below in the notes)
Family change/loss (divorce/separation, remarriage, death in family)
Family not connected to community resources
I am struggling to help student find successes in my classroom
Reintegration back to school from treatment facility
Access to Food
Other (note below)
Supports/Interventions Currently in place (to your knowledge):
Sees counselor/counselor led groups regularly
SPED Social/Emotional/Behavioral Services
County Case Manager
Food 4 Kids Program
PACER or other advocacy group
SPED referral in process/Formal interventions being completed
Best time(s) student is available
Send me a copy of my responses.
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This form was created inside of ISD-200.