Communities In Schools of the Permian Basin
Mental Health Support Referral
Date
*
-
Month
-
Day
Year
Referral Source Name
*
Referral Source Agency or Organization
*
Big Spring ISD
Care Solace
CATR/TCHATT
Department of Family and Protective Services
Ector County ISD
Healthy Kids Clinic
Juvenile Probation
Medical Center Hospital
Midland ISD
Midland Memorial Hospital
Midland Teen Court
Odessa Regional Medical Center
Pecos-Barstow-Toyah ISD
Other
Referral Source's Email
*
example@example.com
School District
*
Please Select
Big Spring ISD
Ector County ISD
Midland ISD
Pecos-Barstow-Toyah ISD
Campus
*
School ID
Student Name
*
Factors Impacting Referral (Select all that apply)
*
Trauma (Specify Below)
Abuse (Victim)
Abuse (Perpetrator)
Aggression
Dramatic Change in Behavior
Severe Bullying (Victim)
Severe Bullying (Perpetrator)
Self Injury
Suicidal Ideation
Suicide Attempt
Anger Management
Grief
Trouble with Interpersonal Relationships
Substance Abuse
Homelessness
Runaway
Extreme Fatigue
Noticeable change in appearance/weight
Sudden change in grades
Increased Isolation/Withdrawn
Absence of Caregiver
Frequent sickness and/or nausea
Incarcerated Household Member
Household mental illness
Apathy
Mood Swings
Persistent tearfulness
Violent outbursts
Physical assault
Sexual assualt
Extreme dependency on staff
Concerning behaviors with food
Persistent trouble concentrating
Consistent behavior problems
Extreme fear or nervousness
Other
Trauma--Specify
Notes Regarding Reason for Referral:
*
Guardian Name
Guardian Email
example@example.com
Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian's Preferred Language
Guardian Aware of Mental Health Referral?
Yes
No
Save
Submit
Should be Empty: