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Section 1 of 2
School Counseling Referral Form-Parent/Caregiver
School Counselors differ from mental health counselors in a way that school counselors provide individual, group, and classroom counseling as short-term and solution-focused for ALL students. Mental Health Counselors provide individual counseling sessions and functions as long-term therapy.

Limitations of virtual school counseling include, but are not limited to, confidentiality, access, and availability. You can read more here: https://schoolcounselor.org/asca/media/asca/PositionStatements/PS_Virtual.pdf

Confidentiality- Information students share with the school counselor is confidential unless student gives the counselor permission to share. The student’s right to privacy is guarded as much as permitted by law, ethics, and school policy. The school counselor is obligated to break confidentiality when there is potential harm to the student or others, concern of neglect or abuse, or a court of law that requires testimony or student records.

At times, the counselor and school-based staff (teacher, social worker, principal, etc.) will need to exchange information about your child (how are they coping in class/online, strategies to help, etc.) All communication will take place only on a need-to-know basis.

E-mail transmissions may contain confidential health information that is privileged and legally protected from disclosure by the Health Insurance Portability and Accountability Act (HIPAA).  This information is intended only for the use of the individual(s) named in the email.  If you are not the intended recipient, you are hereby notified that reading, disseminating, disclosing, distributing, copying, acting upon or otherwise using the information contained in this email is strictly prohibited.

Please be aware that counselors do not check email except during school hours and scheduled evening hours. If this is a crisis or emergency call 911 or go to your local emergency room.

We look forward to a great year and working with you and your family :)


Choose the elementary school that your child/children attends to:
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Saint Thomas ES
Mountain View ES
Mercersburg ES
Montgomery ES
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Grade level of child/children:
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Kindergarten
1st
2nd
3rd
4th
5th
Other…
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Teacher Name (last name only)
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Student Name
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Caregiver's Name and Relationship to child (mom, dad, grandparent, foster parent, etc.)
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Best Phone Number (please enter (xxx) xxx-xxxx)
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What are your concerns?
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Safety/Abuse
Family changes
Access to outreach supports (food, clothing, technology etc.)
My child/children needs support (emotional/behavioral support, academics, grief, etc.)
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I need help:
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Finding a therapist/counselor for my child
Getting my student motivated to work from home
Finding resources for food, clothing, etc.
Getting ideas and suggestions on how to support my child
Getting ideas and suggestions on how to help improve my child's behavior at home
Other…
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Could you please...
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Do a check in with the student
Provide me resources, suggestions and tips on helping my child
Keep my student in mind if you put together any small groups
Contact me so we can talk more
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add "Other"
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Section 2 of 2
Concern about safety/abuse
If you are worried about your child or a child you know that is in immediate danger to themselves or others call 9-11 or take them to the emergency room immediately. If you are worried about the safety or possible abuse of a child contact Child Youth Services at 1800-932-0313 or visit
https://www.compass.state.pa.us/cwis/public/home immediately.
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Choose the elementary school that your child/children attends to:
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Grade level of child/children:
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Teacher Name (last name only)
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Student Name
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Caregiver's Name and Relationship to child (mom, dad, grandparent, foster parent, etc.)
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Best Phone Number (please enter (xxx) xxx-xxxx)
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What are your concerns?
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I need help:
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Could you please...
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Concern about safety/abuse
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