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School Counselor Referral
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Which building does the student you are making a referral for currently attend? *
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Student First Name: *
Student Last Name *
Group: *
Referring Person's Name: *
Relationship to student *
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Best way to contact you *
Please list your phone number: *
Please list your email address: *
Academic & Social-Emotional Reasons for Referral: (Check all that apply) *
Required
If you chose "other",  please list the reason for referral.
I feel he/she needs to see the counselor: *
Please list anything else you would like the counselor to know.
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