2019-20 Wellness Center Counseling Referral for Teachers and Staff DO NOT USE! PLEASE USE 2020-21 VERSION OF THIS FORM HERE: https://docs.google.com/forms/d/e/1FAIpQLScAnuqzRMwn7woQZO3h-8pb8Fe-3sXuQQBGh8Gdn8dkOxH1GA/viewform

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IMPORTANT: We review these referrals ONLY ONCE PER WEEK, usually 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.****

Continuing this year,, 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.

AS OF 1/8/20 WE HAVE A WAITLIST OF 7 STUDENTS AT PHS/MHS AND 3 STUDENTS AT PMS. THEREFORE WE ARE ASKING THAT YOU SPEAK WITH THE STUDENT BEFORE MAKING THE REFERRAL TO CONFIRM THAT THE STUDENT IS AWARE OF THE REFERRAL AND WILLING TO MEET AT LEAST ONE TIME WITH A WELLNESS CENTER THERAPIST.

Name of Student *

School *

Piedmont Middle School

Piedmont High School

Millennium High School

Other:

Grade

Please describe your reason for referring this student. *

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.

This student needs an immediate visit. PLEASE CALL VIKI AT X803 OR BRING STUDENT TO WC.

This student has immediate needs and should be seen within the week. (if you check this option, be sure to tell us why this student should be seen within a week in the description above).

This student is a high priority but could be put on a waiting list.

This student could benefit from counseling but will be okay without it.

Unknown at this time.

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? *

Yes, a private referral could be a substitute for WC counseling.

No, a private referral likely is not a good solution for this student/family.

Unknown at this time.

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.

yes counseling is on IEP

no counseling is not on IEP

unknown at this time

If you answered "yes" to above question, please indicate weekly minutes required by IEP.

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.

Does this student know you are referring them? *

Yes student is aware of referral.

No student is not aware of referral. PLEASE LET STUDENT KNOW OF YOUR REFERRAL AND CONFIRM THAT HE/SHE/THEY ARE WILLING TO MEET AT LEAST ONE TIME WITH A WC THERAPIST.

Does this student's parent/guardians(s) know you are referring them? *

Yes parent/guardian knows of the referral.

No parent/guardian does not know of the referral.

Unknown at this time

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

check in with counselor

standard 10 session Wellness Center service

group counseling

suicide risk assessment*

child abuse assessment*

drug and alcohol assessment

referral to a private therapist

Required

Name of person completing this form and best contact information *

What is the nature of your relationship with this student? *

Anything else you would like us to know?

Wellness Center Actions Taken

For Wellness Center Staff Only

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