CRE Parent Counseling Referral Form

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*This form may not to be used for emergencies. In the event of a life threatening emergency or injury, call 911 immediately.* Please allow at least 24 hours for me to contact you. If you need to speak to me sooner feel free to email me at sandhiry@lisd.net or call me at 972-350-4310. Please make sure you have filled out the Back to School forms giving me permission to meet with you child.

Parent Name (First and Last) *

Parent Phone Number *

Name of student being referred: Last name, First name *

Grade Level *

Pre-K

Kinder

First

Second

Third

Fourth

Fifth

Teacher's name: *

Describe why you feel this student needs to be seen by the counselor. Please keep in mind the student's confidentiality while answering this question. *

I would like the counselor to see him/her *

individually

in a small group

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This form was created inside of Lewisville ISD.