ESU #3
School Mental Health Services
(SMHS) Referral Form

Student must be enrolled in one of the following school districts:

Arlington, Blair, Conestoga, Elmwood-Murdock, Fort Calhoun, Louisville, Plattsmouth, or Weeping Water

(*clicking on each section header will also toggle that section)
Student Information
Student Information ( * required fields )

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

    Yes No
  2. * Does the student require interpretation services?:

    Yes No

    If yes, What service/language:

  3. * Is the student receiving special education services?:

    Yes No
    If yes, who is the case manager?:
  4. * Is the student on a 504 plan?:

    Yes No
Automatic Status
Automatic Status ( * required fields )
  1. * 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 SES, self harm, other (please list):

    Yes No

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

    Yes No

  3. Additional information related to an automatic status / crisis referral?
Parent Caregiver Contact Information
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.

Contact 1
  1. If other relationship:

  2. Yes No
  3. Does the parent/caregiver require interpretation services?:

    Yes No

    If yes, What service/language:

Person Making Referral
Person Making Referral ( * required fields )
  1. If other:

  2. (will populate the below fields from the caregiver contact)
Reason for Referral
Reason for Referral ( * required fields )
  1. *Please provide a brief description of the concern including how long/often the behavior has been occurring:

  2. *Level or Type of Service Requested (only to be completed by school team members):
  3. *Please rate the urgency of the referral (1-10) 1 not urgent, 10 extremely urgent:
Student Assistance Team
Student Assistance Team ( * required fields )
  1. * Has your SAT/Problem solving team made attempts to problem solve at Tier 1 and Tier 2

    Yes No
  2. *Team members present:
  3. *Summarize goals worked on (Please be specific):
  4. *Interventions tried (Please be specific):
  5. *Is this referral the result of universal screening? Yes No
  6. If yes, what screener:

    Date of Screener Administration:

    The student screened is:

  7. *Has the student previously received SMHS? Yes No Unknown
Urgent (This will mark the form as High Priority and urgent will be included in subject line)

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