Middle and High School Referrals | Pajaro Valley Prevention & Student Assistance

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SCREENING & REFERRAL FORM

CONFIDENTIAL

Please complete this form and our team will strive to make a connection with parent/guardian within the first 24-48 hours.

Probation:

Yes

Type(s) of Service

Individual

Family

Drug & Alcohol

Tobacco

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

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.

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