CHS Teacher & Staff- Student Referral to Mrs. Strong, PSW (Psychiatric Social Worker) Services

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Please complete this form if you believe your student would benefit from mental health or social support services. Mrs. Strong will follow up with you within 2 school days.

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.

Please select one of the following: *

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.

Referral-I have NOT notified the family that I am making a referral to the PSW and they are not expecting a contact.

Date of Contact with the parent to inform them of PSW referral

年

月

日

Name of parent contacted

Best contact number/email for parent/guardian *

Name and role of person making the referral (e.g: Ms. Bradley, Teacher) *

Email address of the person making the referral *

Contact phone number of person making the referral. Enter number as follows: xxx-xxx-xxxx *

Name of student (Last Name, First Name) *

Student ID # *

Areas of Concern (Select all that apply) *

Academic Concerns: Does not complete assignments, not connecting to distance learning, lacks motivation

Home Environment: Unstable home environment, parent-child conflict, divorce/separation

Behavior: Withdrawn, disruptive, attention difficulties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

必填

Additional information

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