SFUSD Student Intervention Team - Confidential Mental Health Services Referral Form for
School Based and Educationally Related Mental Health Services (ERMHS)
KEEP COPIES IN BROWN FILE ONLY
REFERRER INFORMATION
(COMPUTER FILL IN VERSION)
Referral Date:
Referral Preparer/Contact Person:
Title:
Phone:
STUDENT INFORMATION
Student Number (H0):
CBHS ID #:
Last Name:
First Name:
Birth date:
Sex:
Primary Language of Student:
M
F
School:
Grade:
Primary Language of Parent:
Student Ethnicity (check all that apply)
African American
Filipino
Japanese
Samoan
Unknown
Chinese
Latino
Native /Eskimo
Caucasian
Other:
Special Education Eligibility:
Special Education Services:
SLD
ED
Inclusion
SLI
RSP
OHI
AUT
SDC
DIS only
Other:
NPS
Date of Current IEP (ATTACHED):
PARENT/GUARDIAN(S) INFORMATION
Parent
Legal Guardian*
Adoptive Parent*
Educational Surrogate*
Foster Parent*
*Documentation of Educational Rights must be included with the referral
Parent 1: Last:
Address:
First:
Parent 2: Last:
First:
City/State/Zip:
Phone(s): Home:
Work:
Cell:
Is parent/guardian aware of this referral for mental health services ?
Is parent/guardian supportive of these services:
Yes
No
Yes
No
Uncertain
STAFF SIGNATURES
Referral Form should be completed in collaboration with the following people. All parties must review and
sign referral.
Staff
Principal/Administrator
Special Education Teacher
School Psychologist
LSP/Grade Level Counselor
General Education Teacher
Other (School Nurse, Wellness
Coordinator)
Print Name
Signature
SFUSD - School Based & ERMHS Referral Form 2011-12
Page 2 of 5
1. To help us better understand the needs of this student, please place a checkmark next to the
behaviors the student is experiencing at school, and indicate the intensity/frequency on the scale
(Low to High). ONLY CHECK BEHAVIORS THAT APPLY.
Intensity/Frequency
LOW
MED
HIGH
Observed Student Behaviors Checklist
1
2
3
4
5
Externalizing
Behavior/
Aggression/
Disruptiveness
Aggressive to others
Defiant, talks back to staff/argues
Disturbs other students/Disrupts class
Fidgety, difficulty sitting still
Impulsive, acts without thinking
Shouts/Screams
Talks out of turn
Internalizing Behavior/
Anxiety/Depression
Daydreams, gets lost in thoughts
Feels worthless or inferior
Fearful, overly anxious, worried
Lethargic, sleeps in class
Apathetic, unmotivated
Unhappy, sad or depressed
Withdrawn
Suicidal, thoughts about harming self
Peer Rejection/
Social Skills
Acts too young for age/immature
Complains of loneliness/lonely
Gets teased or bullied a lot
Doesn’t get along with other students
Difficulty making friends
Shy, timid
Severe Conduct
Cruelty, severe bullying/meanness to others
Destroys property
Gets into many fights
Has brought weapons to school
Gets into trouble with the law
Steals things
Sexualized behavior, touches others inappropriately
Truancy/School
Related
Poor working/study habits
Dislikes school
Poor participation in class
Messy/incomplete work
Frequent absences
Tardy to school or class
Underachieving
Other
Other Behavior:
Other Behavior:
Student Name: ___________________________________ DOB: ________________________Date of Referral:__________
SFUSD - School Based & ERMHS Referral Form 2011-12
Page 3 of 5
2. Refer to the Observed Student Behaviors Checklist. How are emotional and/or
behavioral characteristics marked as High Frequency (4 and 5) on the Observed Student
Behaviors Checklist hindering the student’s ability to access the curriculum? How are
these behaviors adversely impacting participation in the classroom or school
environments?
3. Does the student’s IEP contain a Behavior Support Plan (BSP)?
YES*
NO
*3a. Please ensure that a copy of the BSP with the most recent revisions is included in
the attached IEP.
BSP attached to the referral
*3b. Please detail the student’s response to BSP intervention here:
4. What underlying mental health issues are going on that may be causing the behavior of
concern?
Examples: changes in mood, trauma, changes in home conditions, etc
5. Has there been a formal diagnosis of a mental health condition by a non school
personnel mental health professional?
Yes
Describe:
6. Is the student regularly attending school:
Yes
7. Has the student received disciplinary referrals?
8. Has the student been suspended?
suspension(s):
Yes
No
Yes
No
Describe:
No Reason for referral(s):
Please list reason(s) for
9. What are the student’s strengths?
10. Describe the school based interventions and other services that have been implemented
to address the concerns/behaviors above. For example: school counseling & guidance;
psychological services; parent counseling & training; social work services; behavior
interventions; etc Make copies and attach additional sheets as needed.
Student Name: ___________________________________ DOB: ________________________Date of Referral:__________
SFUSD - School Based & ERMHS Referral Form 2011-12
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11. On-Site Provider Contact Information
Name:
Title:
Date Services Began:
Average Length of Session:
Phone:
Date Services Ended:
30 minutes
45 minutes
60 minutes
Type of Service:
Individual Counseling
Family Counseling
Case Management
Other:
Group Counseling
12. Identify the IEP goal(s) addressed during School Based sessions:
13. Any specific modality used? (i.e. play therapy, cognitive behavioral, social skills group, etc:)
14. Summary of treatment/intervention:
15. Outcome/Response to intervention:
Student Name: ___________________________________ DOB: ________________________Date of Referral:__________
SFUSD - School Based & ERMHS Referral Form 2011-12
Page 5 of 5
To help us better understand the needs of your child, please place a checkmark next to behaviors that
she/he is experiencing at home and indicate the intensity/frequency (i.e. how often the behaviors are
happening. ONLY CHECK BEHAVIORS THAT APPLY.
Observed Child Behaviors Checklist
To be completed by parent/caregiver
LOW
1
Intensity/Frequency
MED
HIGH
2
3
4
Talks out of turn
Defiant, talks back to adults
Angry, sullen or hostile
Fidgety, difficulty sitting still
Impulsive, acts without thinking
Shouts/Screams
Aggressive towards others (people or animals)
Daydreams, gets lost in thoughts
Feels worthless or inferior
Fearful, overly anxious, worried
Often tired/lethargic
Apathetic, unmotivated
Unhappy, sad or depressed
Withdrawn
Suicidal, thoughts about harming self
Acts too young for age/immature
Complains of loneliness/lonely
Gets teased or bullied a lot
Doesn’t get along with other children
Difficulty making friends
Shy, timid
Cruelty, severe bullying/meanness to others
Destroys property
Gets into many fights
High degree of interest in violent video games/ movies
Gets into trouble with the law
Steals things
Sexualized behavior, touches others inappropriately
Poor working/study habits
Dislikes school
Frequent absences or tardy to school
Underachieving
Other Behavior:
Other Behavior:
Student Name: ___________________________________ DOB: ________________________Date of Referral:__________
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