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Bathgate School Counseling Referral Form
Please note Mrs. Ganger is only able to respond to referrals when she is at Bathgate on Mondays, Tuesdays, and every other Wednesdays.
* Indicates required question
Email
*
Record my email address with my response
If the student is in a crisis (threat to self or others, child abuse, disorientated or explosive), and/or if this is an emergency please call 911, or call the Suicide Prevention Lifeline : 1.800.273.8255 ASAP. Do not leave the student alone.
What is the student's full name?
*
Your answer
Grade
*
Choose
K
1
2
3
4
5
What is your full name?
*
Your answer
Referral Source
*
Choose
Teacher
Parent
Administration
Front Office
Other Staff
Student Self-Referral
Is the parent aware of the referral?
*
Please notify the parent that a referral has been made EXCEPT in cases of suspected child abuse
Choose
Yes
No
Parent referral
Student self-referral
Reasons for Referral
*
please check all that apply
Suspected substance abuse
Suspected suicidal ideation
Suspected threat to others
Suspected self harm
Suspected abuse
Student seems sad/withdrawn
Student is visibly emotionally upset
Behavior in class
Conflict mediation
Social concerns
Stress
Issue with peers
Academic concerns
Family issues
Anxiety
Depression
Death/Grieving
Excessive absences
Social skills
Anger management
Low self esteem
Health
Other:
Required
Summary of Concerns
please give specifics of the problem
Your answer
Steps already taken:
*
check all that apply
Not Applicable- student/self or parent referral
Individual contact with student
Parent contact
Discipline referral
Classroom intervention
Referral to SST
Other:
Required
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