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Student Self Referral Form
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Grade
*
6th
7th
8th
Are you or anybody else in danger in someway?
*
(harm to self or others)
No
Yes
IF YES TO ABOVE QUESTION PLEASE TELL ME MORE....
Your answer
I need to talk with you about:
*
URGENT!! Something private right away! (please give a few details below
Grief Issues
Depression
Substance abuse (drugs, alcohol)
Family Problems (divorce, parents, brothers/sisters, other)
Peer/Friend Problems
How others are treating me
Bullying Problems
Feeling better about myself
A friend I am worried about
My angry feelings
Peer Pressure/ Not being able to say "no" and "stop it" when I don't want to do something
Thinking about hurting myself or someone else.
My grades and school work
Planning now for the future
Something else
Other
Required
Is this problem:
Temporary
Gone on for a long time
Clear selection
Other Comments:
Your answer
Please rate the issue or concern on a 1 – 10 scale.
*
1 = Something is wrong, but I am okay. 5 = I need to talk to you sooner than later. 10 = IMMEDIATE DANGER
1
2
3
4
5
6
7
8
9
10
REMEMBER MRS. SCHWEITZER IS PART-TIME, BUT SHE WILL GET YOU AS SOON AS POSSIBLE!
IF THIS IS AN EMERGENCY PLEASE CALL 911
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