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CAES School Counseling Referral 2019-2020
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Parent Referral for Counseling Services
Your Child's Name
Your answer
Referring Adult
Your answer
Date
MM
/
DD
/
YYYY
Best way to contact you to follow up
Your answer
Reason for referral (check all that apply)
Aggression
Dramatic change in behavior
Bullying- target
Bullying- perpertrator
Self-Injury (cutting, biting, head-banging, etc)
Daydreams/ Fantasizes
Anger Management
Physical fighting
Stealing
Lying
Sexualized behavior
Difficulty in peer relationships
Social skills
Changes within the family structure
Parent/ close family member deployment
Cries easily/ often for age
Rigid/ Inflexible
Self-image/ Self-esteem
Grief and loss
Sadness
Worried/ Scared
Defiant
Impulsive/ Hyperactive
Inattentive/ Distracted
Disruptive
Withdrawn
Anxious/ Nervous
Drastic mood shifts
Lacks motivation
Work completion
Organizational skills
Personal Hygiene
Suicidal ideation
Other:
Explanation: Please explain the behaviors checked above, and any additional information the would be helpful.
Your answer
Your child is lucky to have you! Thank you for the opportunity to work with your child.
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