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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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* Indicates required question
Name of referring Parent/Guardian, Caregiver or Adult
*
Your answer
Email (If Applicable)
Your answer
Scholar Name
*
Your answer
Scholar Grade Level
*
K
1st
2nd
3rd
4th
5th
6th
7th
8th
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.
*
Your answer
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.
*
Immediately, as soon as possible (If choosing this, please call or text 865-315-7317)
Sometime today
Sometime this week
Other (See next question)
If you answered "Other" to the previous question, please provide an explanation below.
Your answer
Services Requested (Check all that apply)
*
Meeting with School Counselor
School-based therapy referral
Community-based therapy referral
Other (Please Explain Below)
Required
If you answered "Other" to the previous question, please provide an explanation below.
Your answer
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?
Your answer
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