When to Refer: Red Flags & Green Flags | Marble Psychological Services

The Core Question: When does a struggling student need clinical support beyond school-based interventions?

This guide helps you distinguish between temporary adjustment challenges and clinical mental health concerns that warrant a referral to external therapy or assessment services.

🚨 IMMEDIATE REFERRAL SITUATIONS

Refer immediately (same day) if a student shows ANY of the following:

Suicidal ideation, self-harm, or suicide planning

Disclosure of abuse, assault, or trauma

Substance abuse or regular drug/alcohol use

Severe eating disorder symptoms (restriction, purging, significant weight changes)

Psychotic symptoms (hallucinations, delusions, severe dissociation)

Any safety concern for self or others

Follow your school's crisis protocols. Do not wait to see if symptoms improve.

Green Flags vs. Red Flags: Comparison Guide

Area	Green Flags (School-Based Support Sufficient)	Red Flags (Refer for Clinical Support)
Timeline	Gradual improvement over 3–6 months; student shows progress with school interventions	No improvement or worsening after 4+ months; persistent struggles despite support
Social	Slow but steady engagement; at least 1–2 connections forming by month 3	Complete isolation beyond 4 months; refusal to engage with peers; friendlessness causing distress
Academic	Temporary dip; gradual return to baseline performance with accommodations	Severe, sustained decline; inability to complete work; school refusal; significant gap between ability and performance
Mood	Occasional sadness or frustration; generally able to engage and experience positive moments	Persistent sadness, hopelessness, emotional numbness, or irritability; frequent tearfulness; anhedonia (loss of interest in activities)
Physical	Mild, temporary symptoms (headaches, stomachaches) that resolve within weeks	Chronic physical complaints with no medical cause; significant changes in sleep, appetite, or weight; physical symptoms interfering with attendance
Behavioral	Minor irritability or regression; manageable with school-based support	Aggressive outbursts, defiance, risk-taking behaviors, or self-destructive patterns
Functioning	Able to complete daily tasks (school, homework, self-care) with some support	Significant impairment across multiple areas (school, relationships, self-care, family life)
Response to Support	Positive response to check-ins, accommodations, peer mentoring, or counseling sessions	No response to school-based interventions; worsening despite support; needs more intensive care

The Three-Month Rule

Use this timeline to guide your decision-making:

0–3 months: Monitor closely. Provide school-based support (check-ins, accommodations, peer mentoring). Most students improve during this window.
3–4 months: If no improvement, initiate parent conversation. Discuss concerns and explore whether additional support might be needed.
4+ months: If struggles persist or worsen, strongly recommend external evaluation. At this point, the issue is likely beyond normal adjustment.

TCK-Specific Red Flags

Some warning signs are unique to Third Culture Kids and may not be obvious:

"Performing Fine" but Emotionally Numb: Good grades, polite behavior, but emotionally shut down or disengaged

Serial Social Avoidance: Refusing to form friendships because "everyone leaves anyway"

Excessive Idealization of the Past: Constantly comparing new school unfavorably; refusing to engage with present

High-Functioning Anxiety: Academic success masking perfectionism, burnout, or severe anxiety underneath

Chronic Identity Confusion: Persistent distress about "where I'm from" or "who I am" beyond typical exploration

When NOT to Refer (Yet)

Student arrived within last 3 months (normal adjustment period)

Interventions haven't been tried or implemented for less than 6 weeks

Struggles are clearly due to recent, identifiable crisis (move, family trauma) and improving with support

Student is responding well to school-based counseling and making progress

Concerns are mild and not interfering significantly with daily functioning

Note: Continue monitoring and revisit the decision if circumstances change or symptoms worsen.

Making the Referral: Next Steps

1. Have the conversation with parents (use parent conversation scripts)

2. Provide specific referral options (don't just say "find a therapist")

3. Recommend TCK-informed providers when possible (e.g., Marble Psychological Services)

4. Follow up within 1–2 weeks to see if they've scheduled

5. Coordinate care (with parental consent, stay in touch with therapist)

Trust Your Gut

If something feels off—even if the student doesn't meet clear criteria—that instinct is worth paying attention to. It's better to make an "unnecessary" referral than to miss a student who's struggling.

Sample Referral Language for Parents

"Based on what we're seeing at school, I think it would be helpful for [student name] to talk to someone who specializes in supporting students through [adjustment/anxiety/academic challenges]. This isn't about anything being 'wrong'—it's about giving them tools to thrive. I can recommend a provider who works specifically with international school students if that would be helpful."