Canterbury Social Worker/Counselor Referral

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Provide information needed for the referral below.

**IF THERE IS AN IMMEDIATE PHYSICAL OR MENTAL HEALTH CRISIS

Email *

Record my email address with my response

Student Name *

Grade Level *

Name of person submitting the referral *

Relationship to the student *

Area(s) of Concern (Check all that apply) *

Academics

Attendance

Basic Needs (food, clothing, shelter, utilities, etc.)

Family Change (separation, divorce, incarceration, etc.)

Grief/Loss

Mental Health Concerns (anxiety, depression, etc.)

Social Emotional Needs (social skills, peer relations, control of feelings, etc.)

Required

Provide a brief explanation for your concern *

What have you tried to do to help the situation? *

Any known services student is involved (check all that apply)

Counseling

Psychiatry

Medical

Cuyahoga County Dept of Children and Family Services

Court

Don't Know

None

Have you made contact with Parent/Guardian? *

Yes

I am the parent/guardian

I am the student

If you answered "yes" above, what was the outcome?

If you answered "no" above, why not?

Any additional information you would like the team to know

How can you best be reached? Please list phone #, email, in-person, etc. *

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