HMS Counselor Referral Form
Please submit all counselor referrals here. A school counselor will see the student as soon as possible.
Counselors: Lelia Ferguson (Last names A-L) and Lorrie Brazier (Last names M-Z)

*** This form is not intended for schedule change requests. Please see separate link on counselor page to submit those requests.
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Email *
Student Full Name *
Grade Level *
Person making referral (Full Name) *
Person making referral *
Behavior Concerns: (Please check all that apply.)
School-Related: (Please check all that apply.)
Home: (Please check all that apply.)
Emotional: (Please check all that apply.)
Reason for referral: *
Any additional concerns or history/information? *
Actions taken by the person prior to this referral:
Student is aware of referral: *
Has the parent/guardian been contacted about your concern? *
Priority to see the student: *
Low (soon)
Medium (today)
High (ASAP)
Student Priority
If a student/parent would like follow up regarding meeting, please enter email/phone contact information below.
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