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

Together, We Change Lives

HOME
ABOUT
PROGRAMS
NEWS
EVENTS
CAREERS
CONTACT
DONATE
More

SCREENING & REFERRAL FORM

MIDDLE AND HIGH SCHOOL

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 concent from parent to proceed with referral for PVPSA services

Student wants substance use services through minor consent

I am a Pajaro Valley Unified School District Staff Member

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 1-800-952-2235

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

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

Signs of alcohol or substance use

Self-destructive

Extreme negativism or hopelessness

Compulsive behaviors (overschieving, 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 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.

Thanks for submitting!

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

DONATE

Together, We Change Lives

© 2020 PVPSA.org. All rights reserved. PVPSA is a certified 501(c)(3) nonprofit organization, so all donations are tax deductible. (Tax ID # 770269322).