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Student Referral Form- English

Please complete the form below. Required fields marked with an asterisk *

Referrals will be checked daily (on school days).

If immediate attention is needed, please call SYS Crisis:

Monday - Friday (559) 594-4969; After Hours: 1(800) 320-1616

In case of an emergency, contact 911

If the referring person is a mandated reporter, it is your responsibility to call Child Welfare Services (CWS) immediately to report any suspicion of any type of abuse or neglect: 1(800) 331-1585.

Referral Submission Date*

Answer Required

Name of Person Making the Referral*

Answer Required

Phone Number*

Number Required

Relationship to Student*

Answer Required

Student's Name*

Answer Required

Student's Date of Birth

Answer Required

Student's School

Answer Required

Parent/Guardian Name(s)

Answer Required

Does the student know this referral is being made?

Answer Required

Yes

Parent Contact Phone Number

Number Required

Student Contact Phone Number

Number Required

Reason for Referral (please provide concerns with specific examples)*

Answer Required

This form will be forwarded to:

Lincoln Elementary	Erika Orgeta, Assistant Principal
Rocky Hill Elementary	Joe Patterson, Assistant Principal
WIlson Middle School	Alex Ericson, Counselor
Community Day School	Beth Micari, Principal
Exeter Union High School	Melissa Montes, Counselor (Students A-K)/Lisa Parkin, Counselor (Students L-Z)
Kaweah High School	Christine Wegner, Counselor

This Confidential referral will be addressed by the Administrator/Counselor or referred to other support personnel. If the referral was made by someone other than the student or parent, acknowledgement of the referral will be made; however, no further information may be given due to rules of confidentiality.

Confirmation Email

Email Required