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Ms. Simunic's Teacher Referral Form
Answer a few questions about the student you are referring, and I will do my best to meet with them as soon as I am available.

This form is NOT to be filled out in the event of an emergency. If you are in need of immediate assistance, or are in a crisis situation, please do one of the following:

Dial 9-1-1.
Call or text a 24-Hour Crisis Hotline.
National Suicide Prevention Lifeline: or call 1-800-273-8255 or
Crisis Text Line: or ​Text CONNECT to 741741
Report to the closest Emergency Room.

Confidentiality Note: Confidentiality is a vital part of counseling. I strive to maintain your trust, safety and well being but are bound to ethical standards and must report any information that relates to threat of harm, harm to self, or suspected abuse of any kind.

The information is kept confidential and can only be accessed by the school counselor. Thank you!
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What is the student's name? *
Teacher's name and grade level taught *
How long has this been a concern?
Clear selection
Write a brief description of the student concern
Level of urgency (I will do my best to meet with the student as soon as I am available)
Clear selection
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