Wellness Referral Form 2021-2022

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By filling out this form, it lets the WHS Wellness Team know that you would like one of us to reach out to the student to check in with them. This form is intended for non-crisis counseling referrals. Referrals will be prioritized by the level of urgency and responded to as soon as possible.

Parents: If this is an *emergency* please call 911, and/or take your student to the nearest emergency room. Teachers/Staff: If this is an *emergency* and you do not have immediate access to the counselor, contact the student's parents/guardian, call 911, and/or contact the Suicide Prevention Lifeline:1-800-273-8255.

Email *

Please indicate whether your referral is for a 1x check-in or wellness counseling *

Please provide your name *

Please indicate if you are a parent, counselor, or staff *

Student's ID Number *

Grade Level *

Preference on Wellness Counselor *

Have you spoken to the student directly? *

Yes

Have you contacted the student's parents/guardians? *

Yes

I am the parent

Would you like to talk to us prior to us contacting the student? *

Yes

If you answered 'yes' to the question above, please provide the best contact information (and time)

Reason(s) for referral (check all that apply) *

Social concerns (friendship issues, bullying, conflict mediation, social skills, etc.)

Emotional concerns (stress, anxiety, sadness, low self-esteem, anger, etc.)

Family concerns (grief/loss, divorce, sibling conflict, etc.)

Other:

Required

Is the student in immediate danger? (danger to self or others) *

Yes

Unknown

If yes, Is the student expressing thoughts of suicide? *

Yes

Unknown

Reminder: Emergency level situations must be addressed immediately. If you answered 'yes' to the statement above, and if the student expressed having a plan and means to act on the plan, please call 911 and contact the parents immediately. Please also inform the administrators.

If you do not have immediate access to the counselor and this is a crisis situation, please call 911 and/or contact the Suicide Prevention Lifeline: 1-800-273-8255.

Summary of Concerns *

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