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Counseling Referral Form
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* Indicates required question
Referred by:
*
Your answer
Date
*
MM
/
DD
/
YYYY
Student you are referring
*
Your answer
Moods/Behaviors
*
anxious/worried
depressed/unhappy
eating disorder/body image concerns
hyperactive/inattentive
shy/withdrawn
low self esteem
stealing
Other
Required
School Concerns
homework not turned in/not complete
low test/assignment grades
poor classroom performace
sleeping in class/always tired
sudden change in grades
frequently tardy or absent
new student
other
Relationships
bullying
being bullied
difficulty making friends
poor social skills
problem with friends
boy/girl friend issues
other
Home Concerns
fighting with family members
illness/death in the family
parents divorced/separated
suspected abuse
suspected substance abuse
parent request
other
Comments
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