School Counseling Referral Form
Please complete and submit for the School Counselor's Review
School *
Student's Name *
Your answer
Student's Grade *
Person Referring and Teacher Name if Different *
Your answer
Parent/Guardian Name *
Your answer
Phone Number(s) *
Your answer
Briefly Describe the problem/concern. *
Your answer
What steps have been take to handle the problem/concern? *
Your answer
Has the problem/concern been discussed with the student's parent/guardian? If so, what was the response *
Your answer
Is the parent/guardian aware of the referral? *
What is the best day and/or time to meet with the student? *
Your answer
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