PTS BH Referral

Behavioral Health Referral Form
Pacers Take Space (PTS) is a behavioral health support on campus (W-52) at Grant Union High School. PTS consists of Sharing Circles, one on one counseling/ therapy, and resource coordination services with the goal of lowering the barriers of adversity and providing support and essentials for student well-being. This referral form is for the Behavioral Health department of PTS. Please fill out the following form to the best of your ability. If a student is in a mental health crisis, please call 911.

Referrals may also be made via phone calling extension #21699
Date

MonthDayYear
Date
Referring Party Name*

First NameLast Name
Student's Name*

First NameLast Name
Birthday

MonthDayYear
Student ID Number
Grade Level*

9th10th11th12th
**Please be aware that unless it is an extenuating circumstance, the SBHC will need either the student’s 14 digit BIC Medi-Cal number OR the student’s social security number in order to serve the student**
Reason for the Referral

	Yes	No	Unknown
Does this student have Medi-Cal services?
Is this student interested in therapy?
Is the student aware of this referral being made?
Is parent supportive of therapy services?

What are the Student's treatment goals for therapy?
Please select all that apply in regards to the student’s current emotional/ mental/ behavioral state:*

Sad or depressedCurrent trauma/ History of traumaFeelings of hopelessnessIntrusive thoughtsFights/ is aggressiveLow self-esteem/ negative self-statementsAnxious or fearful moodDifficulty sleepingDiminished interest in activitiesIrritable moodWorries excessivelyDestroys propertyAngry towards others, blames othersRestless and on edgeGrief/ lossPhysical and/or verbal aggression to othersSuicidal ideationHomicidal ideationSelf-harmSuspected auditory or visual hallucinationsOther
Please specifically note any concerning behaviors/symptoms within the last 30 days:
Could the Student benefit from any of the following Resource Coordination?

Receiving information on free local food resourcesReceiving help signing up for EBT and SNAPReceiving help signing up for Medi-CalReceiving transportation servicesReceiving tutoringInformation about sexual health and safetyReceiving help signing up for FAFSAReceiving information about higher education or professional development opportunitiesReceiving Social Services from county (SCOE)Other
Any additional comments/notes:
Clear
Date & Time Out

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Behavioral Health Referral Form