Moulton's School Counseling Referral Form

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Please note Mrs. Ganger is only able to respond to referrals when she is at Moulton on Mondays, Tuesdays, and every other Wednesdays.

If the student is in a crisis (threat to self or others, child abuse, disorientated or explosive), and/or if this is an emergency please call 911, or call the Suicide Prevention Lifeline : 1.800.273.8255 ASAP. Do not leave the student alone.

What is the student's full name? *

Grade *

What is your full name? *

Referral Source *

Is the parent aware of the referral? *

Please notify the parent that a referral has been made EXCEPT in cases of suspected child abuse.

Reasons for Referral *

please check all that apply

Suspected Suicidal Ideation

Suspected Threat to Others

Suspected Self Harm

Suspected Abuse

Student Seems Sad/Withdrawn

Student is Visibly Emotionally Upset

Behavior in Class

Conflict Mediation

Social Concerns

Stress

Issue with Peers

Academic Concerns

Family Issues

Anxiety

Depression

Death/Grieving

Excessive Absences

Social Skills

Anger Management

Low Self Esteem

Health

Other

Required

Summary of Concerns

please give specifics of the problem

Steps already taken: *

check all that apply

Not Applicable (parent or student/self referral)

Individual Contact With Student

Parent Contact

ODR

Classroom Intervention

Referral to SST

PBIS Interventions

Other:

Required

Thank you for your referral! Mrs. Ganger is in the office on Mondays, Tuesdays and e/o Wednesdays to respond to referrals.

Email: bmganger@capousd.org

Phone: 949-234-5980 ext. 60050

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