Confidential School Counseling Referral Form
Student's Name: *
Your answer
Date Submitted *
MM
/
DD
/
YYYY
Student's Grade: *
Your answer
Counselor
Please Indicate the Level of Severity *
Student is referred by: *
Referred by:
Your answer
Reason(s) for Referral – Problems/Concerns related to: *
Clarify Referral Problem/History: *
Please include as much detail as possible.
Your answer
Have you contacted parent/guardian about your concern? *
Submit
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