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Granada 2023/24 (Parent/Caregiver) Counselor Referral Form
Note: This form collects Granada School emails automatically.
Email *
What is your name (First and Last) and how are you related to this student? *
Are you concerned for your child's safety? 
Note: If the student has an immediate need please contact emergency services.
 *
What is your child's name? (First and Last)
 *
What grade is your child in and what is the name of the homeroom teacher (if applicable)?
 *
Who else is aware about this problem ? (check all that apply)
 *
Required
What types of concerns do you have for this student? Check all that apply. *
Required
Please describe why you are referring this student to counseling. 
 *
What (if any) interventions have you already tried for this concern? 
What have you tried so far to help with this problem/situation?
Talked to my parent/guardian
Talked to a teacher or adult
Talked directly to the person who I am having the problem with
Using coping skills (taking deep breaths, walking away, exercise, reading,  etc.)
On a scale of 1-5, how serious (Immediate) is this concern?
 *
Not serious
Very serious
Would you like for the counselor to contact you after she has followed up with this referral? *
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