School Counselor Referral Form 2026-2027

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Hello! It's going to be a great year! Ms. Ervin and Mrs. Yang are your school counselors here at MPMS. Ms. Ervin works with all 8th grade and the 7th grade UNCC Team while Mrs. Yang works with all 6th grade and the 7th grade NC A&T Team. As school counselors, they support students' social/emotional, academics, and career needs. Please complete this form to let them know how they can help this school year.

Students: Complete this form for yourself if you want your school counselor to reach out to you.

Parents/Guardians: Complete this form if you want a school counselor to reach out to your child on specific concerns you may have.

School Staff: Complete this form if you want a school counselor to reach out to a student you have concerns about.

YYYY

I am... (choose only one from the box below)

A student

A parent/guardian

A school staff

Clear selection

Name of person making this referral *

Name of student (first & last) who needs to be seen *

Grade level of student *

6th grade

7th grade

8th grade

Reason (s) for making this referral: (You can check more than one box!) If other, you can type what it is next to that line. *

School (grades, organizational skills, study habits, motivation)

Feelings (anger, sadness, worry, nervous, etc...)

Home/family problems

Behaviors (bullying, self-control, decision making skills)

Friendship problems (drama, gossip, rumors)

Hygiene

Check in

Other:

Required

Submit

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