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RSMS Student's Self-Referral Form
Please, read carefully the options!
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* Indicates required question
Name
*
Your answer
Homeroom Teacher
*
Your answer
Date
*
MM
/
DD
/
YYYY
Middle school counselors!
Who is the person that you are looking for?
*
Ms. Hawkins - Social Worker
Mr. Ortiz - School counselor
How are things at home?
*
Terrible
Ok
Good
Amazing
How are things at SCHOOL?
*
Terrible
Ok
Good
Amazing
Pick One
*
I want to check in with you
I have a small problem I need to talk to you about
I have a BIG problem I need your help with
The area of concern that I have is based on
*
Something happening to ME at school
Something hapening to OTHERS at school
Something happening to ME at home
Something happening to OTHERS at home
Other:
I have tried to solve the problem myself
*
Yes
No
I cannot walk away or let it go
*
Yes
No
This is still going to be a problem tomorrow
*
Yes
No
My teacher is aware of the problem
*
Yes
No
My parent(s)/ guardian is aware of the problem
*
Yes
No
On a scale of 1 to 5 rate the severity of this problem
*
Low
1
2
3
4
5
High
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