Academy Wellness Program Student Referral Form
Thank you for making a referral to the Wellness Center. We will give you feedback after a Wellness Team member meets with the student regarding the status of your referral. Please understand that most services offered to students at the Wellness Center are confidential. Therefore, information can only be shared within the guidelines of the Wellness Initiative's Privacy Policy. 

You can reach Sophie Wasacz, the Wellness Coordinator, at Wasaczs1@sfusd.edu, or at (415) 669-4459, M-F 8:30am-4pm

Please be advised that if you are a mandated reporter and suspect neglect or abuse, you should contact Child Protective Services at 415-558-2650 directly to consult, and then complete a Wellness referral.  

For Academic Concerns Only : please refer student to the Academic Counselor.
For Behavior or Conduct Concerns Only: please refer student to the Academic Counselor
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Referral Source Name, Relationship to Student, and Contact Info. *
Please tell us where to send feedback about this referral. Please include your name, title, and email.
Student First Name *
referral
Student Last Name *
referral
Pronouns *
Grade *
Name of Academic Counselor
Clear selection
Does the student have an IEP? *
Does the student know about the referral? *
**If No, is it OK to let the student know that you referred them to Wellness?
Clear selection
Does the student have attendance issues? *
Please note that it may take us longer to see a student and give you feedback about a student who is often absent.
Is this a BIS (Brief Intervention Services)/ substance use referral? *
Reason for Referral? *
Mark all that apply. Please elaborate in the details section of this form.
Required
Details *
Brief details about your concerns are helpful. (Please feel free to come to the Wellness Center in room 125, or call Sophie, Wellness Coordinator, at ext.1125 to discuss further.)
Student Strengths *
What are the student's strengths and interests that you know of?
Required
Prior Interventions *
Have you addressed this issue with the student? If so, how?  Have you referred this student for other services?  If so, which services or to whom?
Required
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