Thomas Jefferson Middle School 6th Grade Counseling Referral Form
This is a confidential on-line referral form for school counseling services that is ONLY accessible by your school counselors.
Please type first initial and last name of student being referred in the box below:
The student is a:
Please type your first and last name in the box below:
I am a:
parent/guardian of student
Phone number and/or email at which I can be reached:
For parents/guardians only.
Grade Level of Student:
I am referring the above named student for the reason(s)
I am referring the above-named student for the reason(s) checked below:
Difficulty understanding material covered in class
Low test, quiz, or assignment scores
Sleeping in class/Always tired
Sudden change in grades
Frequently tardy or absent
Stress/Anxiety/Pressure to do well academically
Conflict between teacher and student
Please explain in detail reason for referral
Level of Need
Low Need- (Meet with student sometime this week)
High Need- (Meet with student today, it's urgent)
What interventions or strategies you have already tried?
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