School-Based Health Center
Referral for School-Based Therapy & Case Management Services
To be referred for School-Based Services, student must be attending one of the following Anywhere County schools: Anywhere High, Cabell Nowhere High, Nowhere Middle, Somewhere Middle, or the Alternative School
|Date of Referral: |Student Name: |
|Date of Birth: |SS#: - - |School Attending: |
|Student’s Phone #: - |Referral Source: |
|Phone # of Referral Source: - x |Relationship to Student: |
Reason for Referral:
|Difficulty making transition: | new student/freshman | new program |
|Social problems: | aggressive | shy | overactive | other |
|Achievement problems: |poor grades | poor skills | low motivation |
| |
|Major psychosocial or mental health concern: |
|drug/alcohol abuse |depression/suicide |grief |
|dropout prevention |gang involvement |pregnancy support |
|eating problems |physical/sexual abuse |neglect |
|reactions to chronic illness |self esteem |family/relationship probs |
|anxiety/phobia |legal problems |other |
| |
|Other specific concerns: |
| |
Current school functioning and desire for assistance:
|Absent from school: | seldom | 1/month | 2-3/month | 4+/month |
|Overall academic performance: |poor grades | poor skills | low motivation |
|Has the student/family asked for: |Information about service Y N |
| |An appointment to initiate help Y N |
| |Someone to contact them to offer help Y N |
| |
|If you have information about the cause of a problem or other important factors related to the situation, briefly note them here (use the back if |
|necessary). |
| |
Please complete this form electronically and/or print it. Submit to the school’s Health Center or the School-Based Therapist if on-site. If off-site, email to anycounselor@, or fax (555)555-5555.
-----------------------
Follow-Up Confirmation:
Date: __/___/___ Result: □ Met w/ student - □ declined □ awaiting parent consent □ accepted
□ Student unavailable - □ absent □ no show
Date: __/___/___ Result: □ Met w/ student - □ declined □ awaiting parent consent □ accepted
□ Student unavailable - □ absent □ no show
Date: __/___/___ Result: □ Met w/ student - □ declined □ awaiting parent consent □ accepted
□ Student unavailable - □ absent □ no show
Date: __/___/___ Result: □ Met w/ student - □ declined □ awaiting parent consent □ accepted
□ Student unavailable - □ absent □ no show
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