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

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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.

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