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Mid-Buchanan K-12 Referral for Therapy Services
This form can be used to refer a student to mental health therapy services or to seek guidance on a student in the classroom. Please be as detailed as you can in this referral and leave contact information to assist in the referral process.
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* Indicates required question
Email
*
Your email
Name of student you are referring:
*
Your answer
Your name and contact information:
*
Your answer
Date and time of referral:
MM
/
DD
/
YYYY
Time
:
AM
PM
Grade the student is currently in:
*
Choose
Pre-K
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Family dynamics of the student: (write "not sure" if you don't know)
*
Your answer
Reason for referral:
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Sudden Crisis---Loss of loved one, parents getting divorce, adjustment in the household, etc.
Failing two or more subjects
Severe behavior problems
Ongoing mental health struggles
Substance use
Bullying
Ongoing negative peer interaction
Mandated for services through an IEP
Parent Referral
Teacher Referral
Other:
Required
Explanation of Reason for referral:
*
Your answer
Expected outcome/goal for this student if you have one:
Your answer
Teacher/Staff Intervention prior to referral:
Met with student one on one to discuss situation or correct behavior
Met with student and teacher about situation
Met with student's parent/guardian about situation
Referred student to administration
Spoke to School Social Worker regarding situation
Tried different teaching or counseling methods to offer student support for situation/behavior
No intervention yet
Other:
Clear selection
Extra information that would be helpful for Mrs. Utz or elaborate on intervention already used:
Your answer
The best contact person for this student that has first hand knowledge of circumstances (please include contact information on how they can be reached):
*
Your answer
Any services the student is currently receiving or has received in the past, including but not limited to case management, medication management, therapy services, special education services, etc:
*
Your answer
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