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School Counseling Referral Form-Teacher
Please answer the following questions to refer a student for counseling services. This will be for short term individual/group counseling or student check ins.

This form is confidential and only viewed by Mrs. Khaled, the school counselor. 
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Teacher Name *
Student Name *
I am recommending this student for counseling services for support with: *
How severe is the issue?
Not severe at all (can wait to be seen)
Extremely severe (needs to be seen ASAP)
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Give 2 times that would be best for student to be seen for 15-20 min.
Additional Comments/Information
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