Parent Referral Form 2025-2026

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Parents will use this form to request School Counseling support for their child. Please provide some information to help Mrs. Beach best support your child. This will be a brief check-in to provide support with social-emotional needs to best prepare them for success in the classroom. Following the student check in, it may be decided upon that your child may benefit from individual or small group counseling. Collaboration will then take place between yourself, the school counselor, and classroom teacher to ensure these services best meet the needs of your student

Email *

Student Name *

Grade

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

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Teacher *

Area of Concern

Behavior

Anxiety

Emotional Support

Coping Skills

Peer Relationships

Problem Solving

Work Completion

Motivation

Other:

Clear selection

Describe the concern, with details of how it is impacting their behavior and success in the classroom

Please check all the following that you understand and agree to:

I understand that my school counselor provides school counseling services but does not provide therapy.

I understand that my school counselor will break confidentiality if your student has thoughts of hurting themselves, thoughts of hurting others, or if someone is hurting them.

Your student promises to adhere to appropriate student conduct while working with their school counselor.

I allow my student to participate in small group or individual based counseling as determined between the school counselor and student parent(s).

Parent: Please type your name below stating that you have read the above disclosure statements with your child. *

A copy of your responses will be emailed to the address you provided.

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