Independence High School Wellness Program Student Referral Form 2023-24

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Thank you for making a referral to the Wellness Center. 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. We will give you feedback after a Wellness Team member meets with the student regarding your concerns.
Please, be advised if a Wellness member or Jennifer Roffle is unavailable for an immediate consultation, that you are a mandated reporter, and should contact Child Protective Services directly to consult at 1-800-856-5553. In addition, please, complete a Wellness referral if you suspect neglect or abuse.

Academic Concerns: please refer student to Jennifer Roffle, School Counselor
Behavior Concerns: please refer student to an Administrator

Email *

About the person making this referral:

Your Name, Relationship to Student, and Contact Info. *

Please tell us where to send feedback about this referral. Please include your name, phone and/or email.

About the student:

Students Name: *

Student's Cell Phone # (preferred communication for Wellness Staff):

Pronouns: *

Advisory Teacher/Supervising Teacher (ST):

Name of student's Adviser/ST. If possible and appropriate, please inform the student's Adviser/ST about this Wellness Referral.

Does the student know about the referral? *

Yes

No**

**If No, is it OK to let the student know that you referred them to Wellness?

Yes

Clear selection

On average, how often is the student in school? *

Please be advised that it may take us longer to see a student and give you feedback about a student who is often absent.

Usually

Sometimes

Rarely

Reason for Referral? *

Mark all that apply. Please elaborate in the details section of this form.

Anger/Defiance

Cultural Adjustment

Depressed/Withdrawn

Family Concerns

Grief/Loss

Health Concerns/Medical Needs

Reproductive Health

Romantic Relationships

Sexual Identity

Social Relations

Substance Use

Violence Prevention

Other:

Required

Details *

Brief details about your concerns are helpful. Please feel free to come to the Wellness Center or call us to discuss further.

Student Strengths *

What are the student's strengths and interests that you know of?

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?

Submit

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