Referral for Counseling 2015-2016

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Referral form for school staff or parents/guardians who wish to refer a child for counseling

Date *

Student *

Referred By *

Teacher *

Reason for Referral: (Check the appropripriate responses) *

Poor peer relationships

Behavioral issues

Lack of motivation

Family changes (death, divorce, re-marriage, moving, etc...)

Extremely withdrawn

Difficulty accepting responsibility

Sudden change in mood, attitude, or behavior

Academic Difficulties that are impacting self-esteem

Self-Esteem

Other:

Required

Teachers and Staff: Has referral to counselor been discussed with parents? *

Yes

Required

Describe specific behavior relating to referral *

List any interventions and/or assistance that have been offered to the student. *

What would you like your student to be able to learn and accomplish? *

What are some positive aspects relating to this student? *

Urgency of Referral *

Crisis

Within a week

Required

Submit

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