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School Counseling Teacher/Staff Referral Form
Thank you for reaching out to your school counselor. Information students share with the school counselor is confidential. The student's right to privacy is guarded as much as permitted by law, ethics, and school policy. The school counselor is obligated to break confidentiality when there is potential harm to the student or others, concern of neglect or abuse, or a court of law. All communication will take place on a need-to-know basis. Please note I do not check my email out of school hours. If this is an emergency, refer to the school's crisis plan steps.
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Student's First and Last Name *
Your Name and Grade Level/Subject (ex Smith 8th English) *
Please share in a few sentences any background information that initiated this referral. *
Level of urgency
Priority 1 - Immediate attention needed (I am also informing administration)
Priority 2 - Attention is warranted in the next few days
Priority 3 - Please add this student to your list of students to see
Priority 4 - Just wanted to inform you of the situation
 *
Caregiver Information - Student lives with *
Have you spoken to the caregiver about this situation? If yes, please comment briefly in the following question *
If yes, what did you discuss and what did they say?
Has the caregiver requested that I meet with the student? *
Please note any interventions or strategies that you have tried prior to referring *
Is there anything else you need the school counselor to know?
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