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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