Student Support Counseling Referral
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Student Name
*
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Student Grade
*
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Your Name/How You Know Student
*
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Priority Level
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Low (schedule when available)
High (schedule ASAP)
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Reason(s) for Referral (Check all that apply):
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Abuse/Neglect
Attendance/Truancy
Anger/Fighting
Bullying/Peer Conflict
Depression
Family Issues
Gender/Sexuality
Grief/Loss
Health/Hygiene
Self-Harm/Suicidal Ideation
Stress/Anxiety
Substance Use/Abuse
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Clarify Referral Issue(s)/Additional History
*
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Action taken by person making referral, is applicable:
*
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Has anyone contacted a parent/guardian about the issue?
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Yes
No
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Student's Strengths
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Share any positive information that might be useful to know
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