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Anonymous Counseling Referral
A referral for counseling should be made when you believe a student's issue(s) go beyond your own expertise or experience, or when you feel uncomfortable helping a student with this issue. A referral can be made anonymously when you feel the issue is interfering with his/her academic work.
Please enter your concerns below. Be sure to include the referred student's name and a detailed reason for the referral. If you feel this issue needs immediate attention, please contact the Antwerp Police Department at (419) 258-2627 or refer the student to
for additional resources.
Referred Student's Name
Reason for the referral (please be as detailed as possible).
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This form was created inside of Antwerp Local School.