Paloma Elementary Parent/Guardian School Social Worker Referral Form:    
The purpose of this referral form is to request support for your child to promote their success in the school setting. Examples of school-based social worker services include: group counseling, individual counseling, referral to community resources, classroom interventions, student check-ins.

Disclaimer: My role as a school social worker is to work with students on a short-term basis to improve their ability to succeed in school and help reduce barriers to their academic success. Therefore, if you have concerns that are affecting your child outside of the school environment or your child is experiencing challenges that require long-term or intensive treatment, you may choose to refer to your primary care physician for a therapy referral or contact your insurance provider for a list of resources. If you do not have insurance, you may obtain resources by contacting 211 (858-300-1211) or the San Diego Access and Crisis Line at 1-888-724-7240.

Please note that I will respond within a week of the submission. If this is an urgent matter please contact administration directly. Upon submission of referral, you will be contacted for additional information and determination for eligibility of school-based services.
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Email *
Student Name *
Student's Teacher *
Grade Level *
Assistance needed (Check all that apply):  Resources: referral or resources to community resources. Student Check-In: Child is in need of a check-in for social/emotional support. Consultation: need suggestions or help with child's behaviors, emotional state, or other concern at home. *
Required
Level of Need (at time of Referral) *
Has your student experienced any of the following family changes (please check all that apply)? *
Required
Reason for Referral (please check at least 1 box) *
Required
Brief Description of Concern/Need: *
Best number to reach you at *
Parent/Guardian Name *
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