SMHS Digital Referral Form

* First Name:

Middle Initial:

* Last Name:

* Preferred Name:

* Date of Birth:

* School District:

* School Building:

* Grade:

* Classroom or Homeroom Teacher:

* Race:

* Ethnicity:

* Gender:

If other please List:

* Is the student receiving therapeutic services from an outside provider?

Yes

No

* Does the student require interpretation services?

Yes

No

If yes, what service/language:

* Is the student bilingual?

Yes

No

* Is the student receiving special education services?

Yes

No

If yes, case manager:

* Is the student on a 504 plan?

Yes

No

Automatic Status ( * required fields )

* In the past 30 days, has the student experienced any of the following: divorce, death in family, suicide ideation or attempt, removal from home, homelessness/instability, adjudicated parent, change in socio-economic status, self harm, other:

Yes

No

* Our SMH Therapist is aware of this student and/or situation.

Yes

No

Additional information related to an automatic status / crisis referral?

Parent / Guardian / Caregiver Contact Information ( * required fields )

Please fill out at least one Parent/Guardian/Caregiver for this referral.
If more than one, select "add contact" below to add up to 3 contacts.

person_add Add Contact (limit of 3)

Contact 1

Contact 1

* First Name:

* Last Name:

* Relationship to Student:

If other relationship:

* Address:

* City:

* State:

* Zip:

* Email:

* Phone:

Best way to contact:

Best time to contact:

* Lives with Student:

Yes

No

Does the parent/caregiver require interpretation services?

Yes

No

If yes, what service/language:

Person Making Referral (* required fields)

* Person Making Referral:

If other:

Caregiver is making referral

(will populate the below fields from the caregiver contact)

* First Name:

* Last Name:

Title:

* Phone:

* Email:

Reason for Referral ( * required fields )

*Please provide a brief description of the concern including how long/often the behavior has been occurring:

*Level or Type of Service Requested:

Please rate the urgency of the referral (1-10) 1 not urgent, 10 extremely urgent:

Student Assistance Team ( * required fields )

* Has your SAT/Problem solving team made attempts to problem solve at Tier 1 and Tier 2?

Yes

No

* Team members present:

* Summarize goals worked on (Please be specific):

* Interventions tried (Please be specific):

* Is this referral the result of universal screening?

Yes

No

If yes, what screener:

Date of Screener Administration:

The student screened is:

* Has the student previously received SMHS?

Yes

No

Unknown