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.
Student Name *
Please type first initial and last name of student being referred in the box below:
Your answer
The student is a: *
Referred by: *
Please type your first and last name in the box below:
Your answer
I am a: *
Phone number and/or email at which I can be reached:
For parents/guardians only.
Your answer
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: *
Please explain in detail reason for referral *
Your answer
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? *
Your answer
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