Parent/Guardian School Social Worker Referral:

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We are here to support you and your child during these uncertain times. School-based student support services will be offered in accordance with the academic calendar (i.e. services will not occur during scheduled school breaks). We can support students though check-ins and/or school-based short-term counseling to reduce barriers to learning and achieve greater academic success. Credentialed school social workers (SSW) and/or social work interns, under the supervision of a credentialed SSW while accruing internship hours, may provide student support (e.g. SMUSD email, zoom, calls and once in person instruction resumes in person meetings).

It is important that you are aware of some additional information regarding virtual student support. Please read this document and complete the box at the end to confirm that you give your consent for the School Social Worker or Social Work Intern to have a check-in/meeting.

Virtual Supports this year will include student check-ins, short-term individual counseling, skill-based groups (on topics such as emotional regulation, social skills, self-esteem, etc.), socialization opportunities (such as virtual lunch bunch), targeted classroom social-emotional lessons/supports (in addition to weekly social-emotional lessons provided on a weekly basis to all grade-levels), restorative practices (classroom community circles or for conflict mediation purposes), teacher/parent consultation, and outside referrals for more intensive and ongoing needs or community resources. These will be similar once we return to in-person learning.

A Student Check-in Is: a short conversation with a student to check-in on how they are doing, an opportunity to connect and express empathy or discuss coping strategies, a method to monitor their stress reaction, and available to all students. Short-term School-Based Counseling will be available based on severity of need. Long-term and consistent counseling or therapeutic services should be obtained outside of the school district.

Please be mindful that groups will treated similar to a classroom setting with a focus on learning and developing skills. Counseling services related to topics such as divorce, grief/loss, and other trauma-related issues that require more personal information to be shared and processed should be obtained outside of the school district. Some students have and will continue to share personal information but will be redirected for the purpose of protecting confidentiality as privacy cannot be assured in a virtual setting.

I will set up virtual meetings using the Zoom platform as needed to address questions and provide check-ins.

Please know, we are unable to provide crisis care. If urgent support is needed, contact the Access and Crisis Line at 1-888-724-7240, the National Suicide Prevention Lifeline at 1-800-273-8255 or the Crisis Text Line by texting 741-741 from anywhere in US.

Email *

In order to receive services for student check-ins or short-term group/individual counseling, you will need to READ AND CHECK ALL of the following information about potential risks and expectations when utilizing virtual support services: *

I understand that there are risks, benefits, and consequences associated with virtual school-based counseling including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

If a safety concern arises, our steps may include making contact with the parent/guardian and providing resources, calling local law enforcement to conduct a wellness check, or calling for emergency responders to assess for safety.

I understand that there will be no recording of any of the online sessions by either party.

I will assist my child in finding a space that will allow for as much privacy as possible.

I will have my child use headphones if possible.

If the session is interrupted due to technology issues, the SSW will attempt to resume the session. If that is unsuccessful, the SSW will email either me or my student to reschedule the meeting.

At the start of each meeting the SSW will ask for a call back number, the current location/address of my child, and the name of someone with him/her that the SSW could contact if an emergency occurs during the meeting.

While the setting of the meeting has changed, the same behavior expectations remain such as, treating each other with respect, being engaged and present within the meeting, and being dressed appropriately for video meetings. Meetings may need to be ended and rescheduled if these expectations are not met.

Required

In addition to virtual considerations for student supports, please READ AND CHECK ALL of the following information about potential risks and expectations when utilizing support services in both virtual & in-person settings: *

I understand that this consent is required in order for my child to participate in support services. I hereby attest that I am legally authorized to give consent for my child to participate in student support services. If there are stipulations requiring both parents provide consent for services I will inform the SSW/intern of this requirement and provide evidence to support this. I understand that it is my right to accept, refuse, or to stop the services at any time through a written statement to the school site school social worker. This consent will expire at the end of this school year unless otherwise specified.

I understands that within the school district, information will only be disclosed to the extent necessary for the coordination of school-based services with school and district staff in the best interest of my child (i.e. a need to know basis). None of my child’s personal information will be put in his/her permanent record.

I understand that confidential information about my child will not be disclosed to entities outside the school district without a signed release to do so, except as mandated by law.

I understand that school staff are mandated to report suspected child, elder or dependent adult abuse as well as harm to self or others to the appropriate parties.

I understand that in order to in order to build trust and work effectively with the student, confidential information may be withheld or shared with the parent/guardian at the discretion of the school social worker/intern(s) in the best interest of the child.

Required

Student's First Name: *

Student's Last Name: *

Student's Teacher: *

Student's Grade: *

Assistance Needed (Check all that apply): *

Resources: referrals or resources to community resources. Student Check-In: Child is in need of a check-in for social/emotional support. Consultation: Consultation - need some suggestions or help with child's behaviors, emotional state, or other concern at home.

Resources (food, healthcare, counseling, etc.)

Student Check-In (1-2 times)

Short-Term Individual Counseling

Skills-Based Group (Emotional Regulation, Social Skills, Self-Esteem, etc).

Consultation

Other:

Required

Level of Need (at time of Referral) *

Low- "I just have some questions I need assistance with in regards to better serve my child."

Medium- "I believe my child needs services, however there is no immediate need."

High- "I need services for my child as soon as possible."

Has your student experienced any of the following family changes (please check all that apply)? *

Divorce/Separation

Incarceration of caregiver or family member

Adoption/Foster Care

Military service/Deployment

Deportation of family member

Grief/ Death of a loved one

None of the above

Required

Reason for Referral (please check at least 1 box) *

Academic Performance: Low grades/Achievement, Lack of Motivation, Not Working to Full Potential

Anger/Defensiveness

Anxiety/Nervouseness

Attendance Concerns: Frequent absences, Tardies, Nurse office visits

Bullying Victim

Depression

Disturbs Class Routine

Erratic Behavior Changes

Homeless/Transient

Inattentive; Distractible, Constantly Off Task

Irresponsibility, Denying, Blaming

Isolating/Withdrawn

Seeks Constant Attention

Self-Esteem/Confidence

Self Injurious Behavior

Struggles to Make Friends

Student Request

Substance Use

Sudden Outburst (Obscene Language, Fighting, Throwing Objects, etc)

Sleep Disturbances (Insomnia, Frequent Nightmares, Frequent Waking)

Excessive Worries related to COVID-19

Lethargic/Low energy

Other:

Required

Brief Description of Concern/Need: *

Best number to reach you at *

Availability (Please leave some options for days/times that you would be available to talk further) *

Please note that office hours are typically 8:15-3:45. There is more flexibility in a virtual setting, but days/times may be restricted during in-person learning because I split days between San Elijo Elementary and Discovery Elementary.

Parent/Guardian Name. Please note that this will be considered your electronic signature for consent of services. *

Send me a copy of my responses.

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