Confidential Parent/Guardian Referral Form

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Your student’s advisor is the primary contact for communication, support, and advocacy. You also can contact Geoffrey Smith, dean of students, by e-mail at gsmith@sasweb.org or by phone at (931) 463-2134.

Other sources of support include:

Counselor - Lisa Garner at lgarner@sasweb.org
Nurse — Melissa Gilliam at melissagilliam@sasweb.org
Chaplain — The Reverend Molly Short at mollyshort@sasweb.org

Student's Name (first and last) *

Your Name (first and last) *

Your Phone Number and/or Email Address *

What is the best way for us to reach out to you and/or the student of concern (email, Zoom conference, phone call, text, etc)? *

Primary concern(s) (Please check all that apply): *

Dramatic change in behavior

Peer relationships

Family concerns

High level of worry or stress

Pattern of anxious thoughts or feelings

Crying/Tearfulness

Unrealistic fears

Impulsive or hyperactive

Perfectionism

Unhealthy or unsafe choices

Persistent sadness or depressed mood

Jumpy or easily startled

Academic skills

Grief or loss

Extreme mood swings

Restless or on edge

Intense anger or aggressive behavior

Low or decreased motivation

Sleep problems (e.g., always tired)

Withdrawn

Low self-esteem, negative self-statements

Defiant, acting out

Diminished interest in enjoyable activities

Inattentive, distractible

Personal hygiene

Hopelessness, negative view of future

Sudden weight loss or gain

Sexual behavior that is disruptive, coercive, or developmentally inappropriate

Suspected substance abuse

Suspected eating disorder

Suspected suicidal thoughts

Suspected threat to others

Suspected self-harm

Exposure to community violence, other trauma

Other:

Required

Clarify referral problem/history (e.g., observations, how often/long this behavior has been occurring): *

Actions you have taken related to your child (if applicable):

Have you contacted faculty, staff, or an administrator about your concern? *

Yes

Explain below the outcome of faculty/staff/administrator contact (if applicable):

What do you think will help the student experience success?

Did you want to talk to the counselor prior to her meeting with the student? *

Yes

Do you want the counselor to disclose that you submitted the referral? *

Yes

Best times to reach you *

Submit

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