Social Emotional Referral
Please fill in the information below to alert the UMHS counseling staff of of a student in need. If the concern is immediate and involving the safety of the student, please escort the student to the counseling office and followup with a phone call to the counseling office.
First name of student:
Last name of student:
Social Emotional Struggles:
Withdrawn, sadness, negative self talk
Fear, worry, shortness of breath, physical complaints
Angry outbursts, sullen body language
Blurts out, acts without thinking
Danger to others, verbal threats
Educational Program & Supports:
Please explain the details of your your concern:
What has been tried by the student, the family, and the school to date:
Have you talked to the student and guardian/caregiver about submitting this referral?
Do you have any requests, comments, or recommendations for the support team?
Please share your name and your relationship to the individual you are referring for social emotional assistance:
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This form was created inside of El Dorado Union High School District.