Counseling Referral Form
The purpose of this form is to document your referral. Please be sure to enter information appropriately and as completely as possible. Mr. Thomas will be notified by email when your request is submitted.  
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Name of referring Parent/Guardian, Caregiver or Adult *
Email (If Applicable)
Scholar Name *
Scholar Grade Level *
Please give a brief explanation of why you are referring this scholar. Examples include: changes in behavior, grief/loss, anxiety, depression family concerns, social conflict/peer relationships, stress/coping, self harm, etc. *
Urgency of Need ** An emergency with immediate need means that the student is in crisis, in danger of harm to self or fearing for his/her safety. Choosing "immediately" means that you have concern that they should see me before leaving the school. *
If you answered "Other" to the previous question, please provide an explanation below.
Services Requested (Check all that apply) *
Required
If you answered "Other" to the previous question, please provide an explanation below.
Please share any other context or helpful information you think would benefit the counselor in supporting your child. Have you utilized any strategies or supports in addressing your child's needs?
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