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CES Parent Referral Form 2018-2019
This form is for parents/guardians to request counseling services. Any information shared in this form is for the use of the school counselor and will NOT be kept in the any cumulative files. If the basis for your referral is to report any abuse, neglect, or intent to harm, you are urged to contact the Department of Children's Services at 877-237-0004. Thank you for helping me better serve our students.
Student's Last Name
Student's First Name
What category best describes your child's need?
Family Change (move, divorce, separation, death, new baby)
Please share in a few sentences any background information that initiated this referral.
I would like the school counselor to
consult with parent/guardian
arrange parent conference
meet with my child
none of the above. I just want the school counselor to be aware of the situation.
Please provide the best way to reach you. (Ex. provide telephone number or email)
Is there anything else you need the school counselor to know?
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