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2023-2024 GTS MENTAL HEALTH REFERRAL
1. Date of the referral
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2. Which school does this student attend?
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Baldwin School
Brightwood School
Emery Park School
Fremont School
Garfield School
Granada School
Marguerita School
Monterey Highlands School
Northrup School
Park School
Ramona School
Repetto School
Ynez School
Alhambra High School
Mark Keppel High School
San Gabriel High School
3. Name of Referring person:
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4.Title of Referring Person
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Student Self Referral
Parent/Guardian
SSS/GTS Intern
Teacher
School Counselor
MHC/LMHC
District Counselor
School Psychologist /Special Education Team
School Nurse
School Administrator
District Administrator
Mental Health Agency
School Community Coordinator
Other AUSD Staff
5. Did you contact the Legal/Ed Rights Holder to inform them of the referral?
*LEGAL/ED Rights Holder MUST BE NOTIFIED prior to completing a mental health referral for a student.
*
Yes
No
Left a Message
Email
6. Date Legal/Ed Rights Holder was contacted regarding this referral:
*
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STUDENT INFORMATION
7. Student's First & Last Name (Legal)
*
8. Sex
*
Female
Male
Non-binary
Unknown
Other
9. Preferred Name ( If Applicable):
10. Student's AUSD ID Number
*
11. DOB:
*
+
12. Grade
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TK
K
1
2
3
4
5
6
7
8
9
10
11
12
13. Who does the student primarily live with?
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Both parents (same household or shared custody)
Father only (with or without step-parent)
Mother only (with or without step-parent))
Relative/Guardian/Caregiver
Unaccompanied Youth/Minor
Unaccompanied Youth/Minor
14. What is the student's Ethnicity? (check all that apply)
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Middle Eastern
Hispanic or Latinx
American Indian or Alaska Native
Chinese
Korean
Vietnamese
Other Asian
African American/ Black
Native Hawaiian or Other Pacific Islander
Caucasian/White
Other, Please Specify
Other, Please Specify
REASON FOR MENTAL HEALTH REFERRAL
15. Please indicate student's current presenting Mental Health symptoms (check all that apply):
*
Irritability
School Refusal
Chronic Absenteeism / Poor Attendance
Suicidal ideation
Death ideation
Low self-esteem
Threat to others
Lack of motivation
Self-harm
Impulsivity/Hyperactivity
Anger outbursts
Isolated/Withdrawn
Anxious symptoms
Depressive symptoms
Student exposure to trauma
Grief and Loss
Gender/Sexual identity
Psychosis (hallucinations, delusions)
Aggression
Alcohol or Substance use/abuse
If student is currently disclosing suicidal ideation, self-harm or threat to others, please contact your school's site administrator (Asst. Principal/Principal) immediately. If you are completing this referral form after hours, please call 911.
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Yes - I will contact my site administrator
No - No immediate risk
16. Please indicate student's areas of limitation related to their symptoms (check all that apply):
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Daily Living Activities (ie. significant increase/decrease in:appetite, hygiene, sleep patterns, etc.)
Social Functioning (ie. significant increase/decrease in: peer relationships, inappropriate relationships with others, energy levels, etc.)
Concentration and Judgement (ie. significant increase/decrease in: attention, activity, impulsivity, etc.)
Responses to Stress (ie. eloping, withdrawing, avoidance, aggression, etc.)
17. Please further describe the reason that prompted you to refer this student to Mental Health Counseling:
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LEGAL/ED RIGHTS HOLDER'S INFORMATION
18. First Name & Last Name
*
19. Phone Number
*
20. Relationship to the Student
*
21. Legal/ed Rights Holder's preferred language (check all that apply):
*
English
Spanish
Cantonese
Mandarin
Vietnamese
Other, specify
Other, specify
READY TO SUBMIT
This Mental Health Referral is
NOT
intended for mental health crisis support. If a student is currently experiencing a mental health crisis please notify a school administrator.
Once you click NEXT below, this form will sent to the school's Gateway Mental Health/Licensed Mental Health Counselor for review. If you have questions regarding the status of this referral, please contact your school's Gateway Mental Health/Licensed Mental Health Counselor.