Together We ROCK Referral Form

Together We ROCK Referral Form

Please fill out the following details to refer a child to our early childhood mental health consultation service.
Email of the Person Completing this Form
example@example.com
Child's Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Gender
Child's Race/Ethnicity
Home Language(s)
Parent or Guardian's Full Name

First NameLast Name
Parent or Guardian's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent or Guardian's Email Address
example@example.com
Please upload the Consent Form

Cancelof
Primary Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Referral Source
Assigned Staff/Teacher

First NameLast Name
Reason for Referral
Student-Teacher Relationship Scale (Pianta, 2001)

Please reflect on the degree to which each of the statement applies to your relationship with the child.

Rows	Definitely does not apply	Not really	Neutral, not sure	Applies somewhat	Definitely applies
I share an affectionate, warm relationship with this child.
This child and I always seem to be struggling with each other.
If upset, this child will seek comfort from me.
This child is uncomfortable with physical affection or touch from me.
This child values his/her relationship with me.
When I praise this child, he/she beams with pride.
This child spontaneously shares information about himself/herself.
This child easily becomes angry at me.
It is easy to be in tune with what this child is feeling.
This child remains angry or is resistant after being disciplined.
Dealing with this child drains my energy.
When this child arrives in a bad mood, I know we’re in for a long and difficult day.
This child’s feelings toward me can be unpredictable or can change suddenly.
This child is sneaky or manipulative with me.
This child openly shares his/her feelings and experiences with me.

Student-Teacher Relationship Scale (Pianta, 2001)