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School Counseling Referral from parents
Please use this form to refer your child that might need school counseling help.
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* Indicates required question
Your child's LAST Name
*
Your answer
Your child's FIRST Name
*
Your answer
Teacher
*
Your answer
Student Grade Level
2nd grade
3rd grade
4th grade
5th grade
Clear selection
Reason for referral
*
Moving (changing houses, school, etc)
Family changes (divorce, losses, etc)
Anger (must of the time)
Friendship (lack of friends or no willing to have friends)
Worry/scare (must of the time)
Anxious
Other:
Any other concerns about your child
Your answer
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