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Wellness Referral Form
Mission Statement:
To provide distressed students with immediate skills to de-escalate their emotional stress in hopes of preparing them to return to the classroom setting.
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Email
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Your email
Student's Name
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Phone
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DOB
MM
/
DD
/
YYYY
Age
15
16
17
18
19
20
21
22
23
24
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Campus
Fort Meade
Lakeland
Winter Haven
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Referring Staff Member
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Major Key Areas for Referral and Recommendations
Calming Strategies (ex: Anger Outbursts)
Grounding Techniques (ex: Anxiety/Panic)
Resourcing (ex: Self-esteem/Identity)
De-escalation (ex: Relational Conflict)
Coping Skills Enhancement (ex: Potential Substance Use)
Shift and Stay (ex: Refocusing of Negative Rumination)
Encouraging (ex: Discouraged/Sad)
Life-Planning/Motivational Interviewing (ex: Grief/Loss)
Decision Making Skills (ex: Poor Impulse Control/Irrational Thoughts)
Other:
Additional Comments
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