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Teacher Referral to School Counselor
Complete the following form for a counselor referral. This is for non-emergency situations. Contact your school counselor for emergency situations ASAP.
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* Indicates required question
Teacher's Name:
Your answer
Student's Name:
*
Your answer
Grade Level:
Kindergarten
1st
2nd
3rd
4th
Clear selection
Concern/Reason for Referral
Academic
Behavior
Friends
Family
Other
How urgent is this referral?
Not Urgent
1
2
3
4
5
ASAP
Clear selection
Have you contacted parents/guardians?
Yes
No
Other:
Clear selection
I would like the counselor...
to observe this student
to discuss the concerns with me
to meet with the student
Submit
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