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

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SCREENING & REFERRAL FORM

ELEMENTARY SCHOOL AGES 4-12

CONFIDENTIAL

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

Referrer has:

Spoke with Student

Received verbal concent from parent to proceed with referral for PVPSA services

I am a Pajaro Valley Unified School District Staff Member

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

Suicidal completed attempt

Thoughts of suicide including how, where and when I am going to hurt myself or someone else

South County MERT can be reached at 1-800-952-2235

Referral to PVPSA

Wanting to hurt myself or wanting to hurt someoe else

Signs or suspected 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)

Extreme negativism or hopelessness

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

Hitting self, including head-butting, burning, picking, excessibe and/or extreme scratching

Unreasonably fearful, sad, unhappy, or hyperactive

Dramatic attention getting behavior (excessive, uncontrollable crying)

Sudden behavior change (quiet and moody or acting out)

Other Information About The Student

Does the student have Medi-Cal?

Yes

Narrative of Symptoms

Directions: After submitting the form, if the student possesses any symptom the students 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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