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Request to see Dr. Sutherland
Scholar Self-Referral Form “Be a Friend and not a foe” You are Remarkable!
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If you are the parent/guardian completing this referral on behalf of your child, please give your full name.
Your answer
Scholar Name
*
Your answer
Teacher Name
*
Your answer
Grade
*
Pre - Kindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Today's Date
*
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Time
:
AM
PM
Anger Expression
I am feeling:
*
Sad
Happy
Excited
Angry
Disgusted
Scared
Or I just need to talk to a trusted adult (A trusted adult will listen to you, help you, and keep you safe.)
*
A crisis: I must see Dr. Sutherland TODAY! Remember to also tell your teacher or another trusted adult.
Very Important: I would like to see Dr. Sutherland as soon as he can.
Important: I would like to see Dr. Sutherland before the week is over.
“Be a Friend and not a foe”
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