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Care Team Referral 25-26
Thank you in advance for filling out this form. Referral for counseling, CIS, or parent liaison services should be made whenever a student exhibits behavior in a repeated pattern or an unacceptable direction. Any staff member, parent or community member may refer. Students may self-refer. Due process requires that this form be completed. And, when requested, made available to parents. This form is district documentation and is confidential.
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Email *
Email *
Students Name *
Grade *
Date of Referral *
MM
/
DD
/
YYYY
Referred By *
Homeroom Teacher *
Is this urgent? 

( An urgent situation is one that can't wait, and requires immediate attention)
 *
The best time for the student to meet with counseling team (if school staff)
 *
What concerns do you have? *
Was the parent contacted about these concerns?
 *
Please provide information from parent contact. *
Student is being referred for basic needs services (check all that apply):
 *
Required
The student is being referred for counseling services
 *
Reason for Referral
 *
Academic Concerns
Behavioral Concerns
Physical/Emotional Concerns
Family Concerns
Other Information
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