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Teacher Referral Form to See the Counselor
*Please complete and submit the form to refer a student to see the counselor. Once we receive the referral, we will get back to you as soon as possible! Thank you for your time and for everything you do!

-Ms. Edwards & Mrs. Fischer

Referring Teacher's Name
Your answer
Today's Date
MM
/
DD
/
YYYY
Student's Name
Your answer
Grade
Reason(s) for Referral- (Check all that apply)
Action Taken by Teacher Prior to Referral- (Please Check All that Apply)
Have you contacted the parent regarding the referral to counselor?
Additional Comments:
Your answer
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