Community Referrals | Pajaro Valley Prevention & Student Assistance

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SCREENING & REFERRAL FORM

CONFIDENTIAL

Please complete this form and our team will confirm receipt of referral with the referrer within the first 48 hours (2 working days).

Our team will strive to make a connection with referred youth within the first 72 hours (3 working days).

Probation:

Yes

Type(s) of Service

Individual

Family

Alcohol & Other Drugs (i.e. cannabis, stimulants, and more)

Tobacco

Under our cannabis support services, the Thriving Youth and Community Program offers restorative and healing alternatives to suspension. Is this referral an alternative to suspension?

Yes

Immediate Referral to 911/MRT/Psychiatric Care/Emergency Room

Active suicidality including completed attempt

Active suicidality with plan/intent/means

Signs of self-injury

Bruising or physical injuries

South County MERT can be reached at 1-800-952-2335

Referral to PVPSA

Passive suicidality

Thoughts of harming others

Signs of physical abuse, neglect, and/or sexual abuse (e.g. wary of adult contact, fear of going home, physical avoidance)

Signs or suspected domestic violence

Signs of self-injuring behaviors (e.g. cutting or burning self)

Vaping nicotine or smoking cigarettes

Signs of alcohol or substance use (vaping marijuana)

Self-destructive

Extreme negativism or hopelessness

Compulsive behaviors (overachieving, smoking, stealing, lying about the obvious)

Unexplained weight loss or gain

Nervous/Anxious

Unreasonably fearful, sad, unhappy, or hyperactive

Dramatic attention getting behavior

Sudden behavior change (quiet and moody or acting out)

Other Information About The Child/Youth

Does the child/youth have Medi-Cal?

Yes

Narrative of Symptoms

Upload File

Upload supported file (Max 15MB)

Directions: After submitting the form, if the child/youth possesses any symptom they shall be referred to PVPSA for a complete assessment. Your assistance in describing the symptoms or observations will aid in the assessment process.

Thanks for submitting! We have added you to our outreach list!

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