Group & Individual Counseling Referral Process by J7G2UPN

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									                    Group & Individual Counseling Referral Process

Hello Willett Staff -

        I am seeking your help in identifying students whom you feel would benefit from small a
group counseling experience. During each session, students will take part in a variety of
activities, such as discussions, scenarios, role-playing, games, and other activities. Students are
offered the opportunity to discuss concerns in a safe, confidential, and supportive environment
amongst their peers. A total of 2 to 3 groups will be held (with a maximum of 6 - 8 students
each). Groups will meet for 8 to 10 weeks for 30 to 45 minute sessions (depending on group
topic and grade level). Students will be responsible for completing any missed work and all
homework assignments. Groups will begin in mid October. More information regarding specific
curriculum, dates, times, and locations for each group will be handed out once that becomes
available.

        Attached you will find a Group Counseling Referral form. After the topic, please
indicate the name(s) of your students whom you would recommend. Based on the needs of each
student at Willett, groups will be finalized, and selections will be made. If one of your students
is selected to be in a group, teachers and parents will be notified, and permission slips will be
handed out accordingly. Students not selected for a group will be placed on a waiting list. More
groups could may be added later in the year.

        Also, a select few students will have the opportunity to participate in individual
counseling. Students who benefit from individual-type counseling usually require intensive one-
on-one time and have needs that cannot be met within a group setting. However, this does not
mean students who participate in individual counseling cannot also participate in group
counseling. Attached you will also find an Individual Counseling Referral form. Students who
are referred for individual counseling will be interviewed, along with parents, and teachers. If
one of your students is selected to be in individual counseling, teachers, and parents will be
notified, and permission slips will be handed out accordingly. Sessions will meet for 8-10 weeks,
and will begin in mid October. More information regarding specific group names, dates, times,
and locations will be handed out once that becomes available.

       Please return both referral forms to me (envelope on my office door) or to Jordan
Mulder’s box as soon as possible (but no later than October 12th). I will be at the October 7th
staff meeting to answer any questions. In the meantime, please let me know if you have any
other questions, comments, or concerns.

Thank you,

John-Michael Gomez
School Psychologist (Intern)
Davis Joint Unified School District
jgomez@djusd.k12.ca.us
                             Group Counseling Referral(s):
                                **CONFIDENTIAL**

Staff Name: ___________________________________________________

Grade: _______________________ Room: _________________________

   Friendship/Social Skills – for students who seem to be lacking in social skills.

     Recommended Student(s):               Gender:       Room:          Grade:
     _____________________                 _____         _____          _____
     _____________________                 _____         _____          _____
     _____________________                 _____         _____          _____

   Anger Management – for students who have shown temper problems or who have been
     identified as being angry or rebellious.

     Recommended Student(s):               Gender:       Room:          Grade:
     _____________________                 _____         _____          _____
     _____________________                 _____         _____          _____
     _____________________                 _____         _____          _____

   Stress-Management – for students who do not deal with pressure well. This could
     include test anxiety, or chronic problems that relate to stress.

     Recommended Student(s):               Gender:       Room:          Grade:
     _____________________                 _____         _____          _____
     _____________________                 _____         _____          _____
     _____________________                 _____         _____          _____

   Self-Esteem – for students who you feel do not have good feelings about themselves.
     These students may be overly shy, passive, submissive, or quiet. They could also be
     compensating for their lack of self-esteem by showing a superior attitude or being a
     braggart.

     Recommended Student(s):               Gender:       Room:          Grade:
     _____________________                 _____         _____          _____
     _____________________                 _____         _____          _____
     _____________________                 _____         _____          _____

   Attention – for students who have difficulty following instructions and whose problems
     could be related to an attention deficit disorder (ADHD).
  Recommended Student(s):             Gender:        Room:         Grade:
  _____________________               _____          _____         _____
  _____________________               _____          _____         _____
  _____________________               _____          _____         _____

 Other Recommended Topic: ___________________________________________

  Recommended Student(s):             Gender:        Room:         Grade:
  _____________________               _____          _____         _____
  _____________________               _____          _____         _____
  _____________________               _____          _____         _____



   Please Return to Jordan or John-Michael (envelope on office door or in mailbox) by
                               October 12th. Thank you!
                           Individual Counseling Referral(s):
                                 **CONFIDENTIAL**

Please Note: Students who benefit from individual-type counseling usually requires more
intensive one-on-one time and have needs that cannot be net within a group setting.


Staff Name: ___________________________________________________

 Grade: _______________________ Room: _________________________

   Recommended Student: _________________________________________________

   Presenting Problem (be as specific as you can, when did it start, how does it affect
   the student, how does it affect you, etc.):
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________

   Estimate the severity of the above problem:
   Mild ___, Moderate ___, Severe ___, Very Severe ___



   ----------------------------------------------------------------------

   Recommended Student: _________________________________________________

   Presenting Problem (be as specific as you can, when did it start, how does it affect
   the student, how does it affect you, etc.):
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________

   Estimate the severity of the above problem:
   Mild ___, Moderate ___, Severe ___, Very Severe ___

 Please Return to Jordan or John-Michael (envelope on office door or in mailbox) by October
                                     12th. Thank you!

								
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