FOR SW

OFFICE USE
ONLY

ATLANTA PUBLIC SCHOOLS

SCHOOL SOCIAL WORKER REFERRAL FORM
This form should only be used to report Child Abuse or Suicidal concerns.

Date of Referral:      

Student Name:       I. D. Number:       Date of Birth:     

School:       Grade:       Homeroom:      Sex: M F

Name of Referring Person:       Title:      

Parent/Guardian:      

Address:      

Home Phone:       Emergency Contact Name:      

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THIS SECTION TO BE COMPLETED BY REFERRING PERSON

REFERRAL TYPE (X BRIEF NARRATIVE: (Describe the problem, and if known, include supporting information, dates and location.)
  (check one) )     
Child Abuse/Neglect
Alleged Teacher/Student
Abuse
Suicidal Ideation

Approved by:       Title:      

***DO NOT WRITE BELOW THIS LINE***
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SOCIAL WORKER’S REPORT:
Case Summary:      
(X
INTERVENTION TYPE
)
Referral does not meet case
criteria. (See case summary)
Date:       Case Code:       Social
CPS Intake Completed Worker:      
Suicide Behavior Toolkit
Completed
Mobile Crisis Unit Contacted
Parent/guardian contacted
Resource Officer Contacted
Referral to Contracted Mental
Health Provider
Home/Agency Visit
Case Continued
Case Closed