Social Work/School Counselor Referral

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Provide information needed for the referral below.

**IF THERE IS AN IMMEDIATE PHYSICAL OR MENTAL HEALTH CRISIS

Wendy Burkey - School Social Worker

Pamm Ohlinger - School Counselor

Email *

Record my email address with my response

Student Name *

Grade Level *

Name of person submitting the referral *

Relationship to the student *

Area(s) of Concern (Check all that apply) *

Basic Needs (food, clothing, shelter, utilities, etc.)

Family Change (separation, divorce, incarceration, etc.)

Grief/Loss

Mental Health Concerns (anxiety, depression, etc.)

Social Emotional Needs (social skills, peer relations, control of feelings, etc.)

Required

Provide a brief explanation for your concern *

Have you made contact with Parent/Guardian? *

Yes

I am the parent/guardian

I am the student

Any additional information you would like the team to know

How can you best be reached? Please list phone #, email, in-person, etc. *

Send me a copy of my responses.

Submit

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