Student Assistance Program Referral

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Please use this form below to submit a referral for Timber Creek's Student Assistance Program. This form will be kept confidential. Please fill out to the best of your knowledge.

The Student Assistance/Mental Health Assistance Program's primary responsibility is to promote social, emotional, and personal development of all students. The program made up of a Student Assistance Counselor/SAC (Mrs. Hohl), Mental Health Assistance Counselor/MHAC (Mrs. Reese), and Student Mentor (Mr. Thompson). The program includes, but is not limited to; anxiety, depression, substance use, school stress, personal conflicts, character development, and anything that is holding a student back from being able to reach their full potential while at Timber Creek.

Email *

Last Name of Student *

First Name of Student *

D.O.B.

Person Submitting Referral *

What is your relation to the student? *

Contact Number *

Reason for Referral *

Attention Deficits

Anger

Anxiety

Bully/ Peer Relations

Child of Substances Abuser (COSA)

Depression

Divorce

Domestic Violence

Family/ Family Relationships

Gender Identity

Grief/Loss

Health Concerns

LGBTQ

Trauma

Opposition/Behavior

Pregnancy

Self Esteem

Isolation Concerns

Social Skills

Smoking/Alcohol/Drug Use

Stress Management

Other:

Required

What school-based interventions has this student already received and what was the outcome?

What school counselor interventions have already been attempted and what was the outcome?

Any other school faculty involved with interventions for this student? Who are they?

Is this student receiving any outside services? If so, what are they?

Does this student have any academic services?

IEP

504

I&RS

AIP

Clear selection

Is the student aware you are making this referral? *

Yes

Is the student's parent/guardian aware you are making this referral? *

Yes

Yes, I am the parent.

My student would benefit from the following type of service:

Individual Counseling

Group Counseling

Outside Counseling Referral

Meeting with School Counselor.Case Manager

My Student Does Not Need Assistance at this Time

Clear selection

Please add any detailed/additional information to take into consideration with this referral (most recent concerns, poor attendance, suspensions, grades, recent counseling services/IOP/PHP, increasing behaviors, high risk behaviors, etc)

I give permission for my student to be contacted through this given cell phone number to set up appointments and to meet virtually (If applicable). Please provide students personal contact number.

Submit

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