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FOR STAFF- Sylmar Charter High School: PSW Referral
Please complete this form if you believe your student would benefit from mental health or social support services from Ms. Montes (Tee) and/or Ms. Toscano.
This form is not intended to be used for an emergency or crisis situation. In the event of a suicidal student, the site administrator must be informed immediately. In the event of suspected child abuse, please follow district protocol and reporting procedures.
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* Indicates required question
Please select one of the following
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I would like to consult with the PSW about a student
Referral-I have notified the family that I am making a referral to the PSW and they are expecting a contact.
Student's ID #
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Your answer
Student's Initials (Example: Jane Doe= J.D.)
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Your answer
Name of Person Making the Referral:
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Your answer
Your Email (to provide you an update):
Your answer
Role of Person Making the Referral:
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Administrator
Teacher
Counselor
Other:
Areas of Concern (Select all that apply)
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Academic Concerns: Does not complete assignments, not connecting to distance learning, lacks motivation
Home Environment: Divorce/separation, unstable home environment
Behavior: withdrawn, disruptive, attention difficulties
Mood: Anxious, depressed, low-self esteem, irritable
Medical/Physical: Dental, Vision, health concerns
Community Resources: Food Banks, community resources etc....
Grief and Loss
Required
Additional information
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Your answer
(If applies) Date of Contact with Parent to inform them of PSW referral:
MM
/
DD
/
YYYY
(If applies) Name of Parent Contacted:
Your answer
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