PVPSA | Santa Cruz County Thriving Youth and Community Referral Form

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Santa Cruz County Thriving Youth and Community

MIDDLE AND HIGH SCHOOL REFERRAL FORM

CONFIDENTIAL

This is a confidential form. Completion of this form signifies your concern for the health
and wellbeing of a student. Those who refer will remain confidential.

Completa esta página en español.

Referrer has: * Required

Spoken with Student

Spoken with Parent

Services Being Requested

Pathway one - Prevention: Stanford prevention toolkit
Pathway two - Intervention: Seven Challenges group sessions
Pathway three - Cessation: Project EX group sessions

**All pathways integrate positive youth development programming with Invincible Youth (IY) with
additional skill building and youth leadership opportunities with Friday Night Live (FNL).

Behavior Signs

Poor grades and/or failure to turn in homework

Persistent absenteeism

Difficulty concentrating

Lack of motivation-apathy

Signs of alcohol or substance use

Talks freely of drug use

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

Withdrawn

Overeating, under-eating

Wary of adult contact or defensive

Fighting

Dramatic attention getting behavior (excessive, uncontrollable crying)

Sudden behavior changes (quiet and moody or acting out)

Signs of neglect or physical or sexual abuse

Avoids being touched, fearful of going home

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

Quarrelsome and uncooperative with teachers and classmates

Defiant

Constant health problems (headaches, stomachache) or frequent nurse visits

Bruising or physical injuries

Poor hygiene

Depression

Anxiety

Psychological Signs

Low self-esteem

Nervous/anxious

Self-destructive

Poor coping skills

Unreasonably fearful

Sad and unhappy

Extreme negativism or hopelessness

Hyperactive

Other

Family Background Information

Fearful of going home

Lives with someone other than parent

Running away

Recent Loss (move, divorce, death)

Family problems (financial, emotional, health)

Concern regarding alcohol/drug use

Domestic Violence

Other

Current Related Services Received

Student Study Team (SST)

Resource Specialist (RSP)

Special Class

School Psychologist

Migrant

CPS

Other

Strengths

Verbal

Auditory

Academics

Kinesthetics

Athletic

Friendship

Musical

Extra-curricular participation

Is there any additional information you will like to share about this student?

Thanks for submitting!

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

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