BCHS Counselling Referral Form
Please note that this form will not be checked on the weekends. If you have an urgent need, or are in immediate danger, you should go to an Emergency room ASAP. You can also reach the Kids Help Phone 24/7 at 1-800-668-6868.
Mrs. Mazereeuw and Mrs. McGinn will be able to see your responses.
making a referral regarding a student I am concerned about.
a student, interested in talking to someone.
If you are referring a student, do they know you are doing so?
Name of Student (Last name, First Name): If making a referral, please include your name as well.
The best class to take me from is:
I would like to talk to somebody about:
If you are making this referral for a student, please provide any relevant additional information below (as well as your name):
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This form was created inside of Pembina Hills School Division.