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

1. * First Name:
2.   Middle Initial:
3. * Last Name:
4. * Preferred Name:
5. * Date of Birth:
6. * School District: Arlington Blair Conestoga Elmwood-Murdock Fort Calhoun Louisville Plattsmouth Weeping Water
7. * School Building:
8. * Grade: 01 02 03 04 05 06 07 08 09 10 11 12 KG PS
9. * Classroom or
   Homeroom Teacher:
10. * Race: Alaska Native American Indian Asian Black African American Native Hawaiian or other Pacific Islander White Unknown / I do not wish to provide this information
11. * Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown / I do not wish to provide this information
12. * Gender: Male Female Transgender Unknown Other
    
    If other please List:
13. * Is the student receiving therapeutic services from an outside provider?:
    
    Yes No
14. * Does the student require interpretation services?:
    
    Yes No

    If yes, What service/language:

15. * Is the student receiving special education services?:
    
    Yes No
    If yes, who is the case manager?:
16. * Is the student on a 504 plan?:
    
    Yes No

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?
   

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.

1. * Person Making Referral: Select Person Making Referral School Staff Parent Guardian Caregiver Other (please list)

   If other:

2. Caregiver is making referral: (will populate the below fields from the caregiver contact)
3. *First Name:
4. *Last Name:
5. Title:
6. *Phone:
7. *Email:

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): Select Level of Service Individual Services Small Group Services Acute Care / Short Term Services Unsure
3. *Please rate the urgency of the referral (1-10) 1 not urgent, 10 extremely urgent:

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:

   At Risk Significant Within Normal Limits Other
7. *Has the student previously received SMHS? Yes No Unknown