Mental Health Services Referral Form - Pasadena Unified School District

Download a blank fillable Mental Health Services Referral Form - Pasadena Unified School District in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Mental Health Services Referral Form - Pasadena Unified School District with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

CONFIDENTIAL

PASADENA UNIFIED SCHOOL DISTRICT

Mental Health Services Referral Form

2046 N Allen Ave, Room 100, Altadena CA 91101

Phone: (626) 396-5920 Fax: (626) 791-6251

Email:

mentalhealth@pusd.us

Student Information

Name:

Date of Referral

School:

Grade:

Student PUSD ID#

Referring Person:

Referring Person Ph. #:

Parent/Caregiver Name:

Parent/Caregiver Ph. #:

Parent/Caregiver Language:

Student DOB:

_______________________

Briefly describe why you are making this referral at this time:

Does this student need to be seen immediately (suicide risk, danger to others, etc.)?

YES

If this is the case, do not hesitate to notify an administrator, counselor or school nurse.

PROBLEM AREAS (CHECK ANY OF THE FOLLOWING)

School Performance

Behavior

Emotional

Social

doesn’t complete assignments

argumentative

sad

doesn’t get along with peers

lacks motivation/uninterested in school

low frustration

anxious/nervous

teased/disliked by peers

frequent tardiness

defiant

irritable/angry

prefers younger children

poor attendance

substance abuse

feels worthless

isolated/withdrawn

short attention span

not using toilet

feels unloved

suspected gang involvement

moves constantly

aggressive

mood swings

negative leader

leaves class/school

steals

outbursts

self-harm

Trauma/Loss

Medical/Physical

Modification(s) tried:

victim of violence

poor hygiene

small work group

has 504 Plan

witness to violence

has vision needs

behavior contract

has IEP

traumatic experience

has hearing needs

simple assignments

death/injury of family member/friend

has dental needs

SST Referral

police report made

appears tired

referral to office

other: __________________________

frequent trips to nurse

change of seat

under / over weight

peer helper

parent/caregiver contact

Please notify Parent/Caregiver prior to submitting form.

Parent has been notified by person making referral

Yes

Submit referral by fax to (626) 791-6251 or by district mail to: Burbank – Mental Health – Clinical Director

REFERRAL DISPOSITION – FOR OFFICE USE ONLY

Referral received: _______

Parent group referral

Declined services

Ineligible

Referred to onsite MH agency

Approved MH services

Funding issue

Intake schedule

Other: _____________________________________

PUSD MH Support Staff Name: ________________ Date:______________________

"Privacy Notice: This message, and any attachments, is intended only for the use of the individual or entity to which it is addressed and may contain

information that is privileged, confidential, or exempt from disclosure under federal or state law. If the reader of this message is not the intended recipient or the

employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of

this communication is strictly prohibited. If you have received this communication in error, please notify the sender and destroy this document and all

attachments."