Wellness Referral Form
School Support Services
Social Work
Student Wellness Referral
Partnering to support student emotional, social, and academic well-being. Please complete this form with observed behaviors.
Confidential Portal
Student Full Name
_________________________________
Grade / Class
__________
Date
__________
Referred By (Staff Name)
_________________________________
Role / Relationship to Student
_________________________________
Primary Areas of Concern (Check all that apply)
Sudden behavior change
Peer conflict / Isolation
Academic drop / Attendance
Frequent crying / Anxiety
Suspected trauma / Grief
Basic needs (food, clothing)
Other (please specify in notes below)
Urgency Level
Routine Support
Moderate Priority
Immediate Crisis
Detailed Observations & Relevant Context
Please describe any specific incidents, timeline of behavior, or attempted interventions.
Social Work Action Plan (Office Use Only) Case Ref: _________________
Date Received
Assigned Worker
Initial Action
Information contained herein is strictly confidential and protected by privacy laws. Thank you for advocating for our students.
