WELLBEING REFERRAL FORM

WELLBEING REFERRAL FORM
IF THERE IS AN URGENT NEED (CRITICAL INCIDENT OR NEED FOR MANDATORY REPORTING), PLEASE IMMEDIATELY INFORM THE HEAD OF STUDENT WELLBEING AND/OR THE RELEVANT DEPUTY PRINCIPAL.
Student Name*
Sub-School*

PrimarySecondary
Class*
Date of Referral*

DayMonthYear
Date
Name of person referring*
Who is aware of this referral*

StudentParent(s)LCC Learning SupportExternal psychologist, counsellor, therapist, etc. (please provide supporting documents/information)Department of Families, Fairness, and Housing (DFFH / DHS) Please provide supporting documents/informationOther
Referral information*
File Upload*

Cancelof

Student behaviours:*

	Not at all	Slightly	Moderately	A lot
Having difficulty making / keeping friends
Not accepted or liked by peers
Physically aggressive
Verbally aggressive?
Withdrawn, shy, lacking confidence? (eg. not engaged, sitting on periphery)
Lacking in organisation and not handing in work
Impulsive, acts without thinking
Exhibiting unusual mood or behaviour
Marked changes in mood or behaviour (e.g. sudden withdrawal)
Friends alert teacher to concerns about student
Increased absenteeism
Disclosed intention to self-harm
Displaying any signs of an eating disorder

What is the level of distress to the student?*

LowMedumHigh
What is the level of distress to the class/peers?*

LowMedumHigh
Reason for referral (select as many as you need):*

AbsenteeismSchool refusalFinancial need (books, uniform, etc.)Welfare (food, hygiene)New studentGrief/lossMental Health (anxiety, depression, trauma, etc.)Family concernsBehaviouralNeurodiversity (ASD, ADD, ADHD, disorder, etc.)Chaplaincy/counselling supportSpiritualityOther (please explain below)
Reason for referral (select as many as you need):*

AbsenteeismSchool refusalFinancial need (books, uniform, etc.)Welfare (food, hygiene)New studentGrief/lossMental Health (anxiety, depression, trauma, etc.)Family concernsBehaviouralNeurodiversity (ASD, ADD, ADHD, disorder, etc.)Chaplaincy/counselling supportSpiritualityOther (please explain below)
Detailed reason for referral (please be as detailed as you need to be):*
Supporting Documentation:*

There are additional supporting documents (e.g. file from previous school, specialist reports, etc.) attached.No additional supporting documentation attached.
SEQTA Notes - ESSENTIAL:*

I have ensured that all supporting notes have been documented in SEQTA (Please tick)
This Wellbeing Referral will be automatically sent to the relevant staff to be actioned and this Form will be kept on file (Confidential)
Should be Empty: