2018-19 Wellness Center Counseling Referral for Teachers and Staff
IMPORTANT: We review these referrals ONLY ONCE PER WEEK on Thursday mornings.

****If you are making a referral that needs immediate attention and the student needs to be seen TODAY (e.g., suicide or harm to other risk assessment), please follow your online referral with a phone call to Viki Salazar x 803 or bring student to the Wellness Center or the Counseling office.****

Beginning in 2018-19, the Wellness Center will be maintaining a waitlist for services due to increasing referrals and a need to keep our therapist caseloads at manageable levels. You will be notified if the student you are referring will be placed on the waitlist. To allow movement on the waitlist, most students will be limited to 10 sessions per school year except in special circumstances (e.g., IEP mandated, immediate crisis, safety concerns, lack of family resources/willingness to provide private services, etc.). Please contact Alisa Crovetti or Amy Hazer for more information on the waitlist and session limits.

Name of Student *
Your answer
School *
Your answer
Please describe your reason for referring this student. *
Your answer
Please rate the urgency of this referral. *
The Wellness Center sometimes receives more referrals that we can assign to interns. Please help us know the best way to triage.
Is this a family who could be open to a referral to a private therapist if ongoing counseling services are not immediately available at the WC? *
Are you referring the student because counseling has been added to his/her IEP? *
Please note that we will not accept IEP based referrals unless the referral has been approved by Dena McManis. Please contact Dena for referral procedures.
If you answered "yes" to above question, please indicate weekly minutes required by IEP.
Your answer
If you answered "yes" to above question, please list the counseling goal(s).
Please note that we ask for no more than 2 counseling goals for Wellness Center Interns.
Your answer
Does this student know you are referring them? *
Does this student's parent/guardians(s) know you are referring them? *
What services would you and/or the student like to see the student receive? *
Please check all that apply; for * items, please bring student to Wellness Center immediately and complete form later
If you answered "ongoing individual counseling" above and are a counselor, case carrier, or have access to the student's schedule, please list all periods that will work as a time for regular, ongoing sessions (e.g., free periods, TA periods).
Your answer
Name of person completing this form and best contact information *
Your answer
What is the nature of your relationship with this student? *
Your answer
Anything else you would like us to know?
Your answer
Wellness Center Actions Taken
For Wellness Center Staff Only
Your answer
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