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School Counseling Referral Form 2022-23
Please fill out the form below to see your school counselor.
NOTE:
Counselor does not check this form or e-mails after hours or over the weekends. If this is an emergency, please find the nearest adult that can assist you, or you can access help using the following websites:
https://www.saysomething.net/
or
http://www.integratedfamilyservices.net/
(click top right corner to live chat with a mental health professional)
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* Required
Student LAST Name
*
Your answer
Student FIRST Name
*
Your answer
Email Address
*
Your answer
What is your grade level?
*
Grade 6
Grade 7
Grade 8
What is the reason for your request?
*
1 point
Conflict
Behavior
Personal
Emotional
Assistance with resources
Friends
High School/College Planning
Scheduling Issues
Academics (Grades)
Goal setting and organization
Family
Bullying
Provide some details regarding the above.
*
1 point
Your answer
Date
*
MM
/
DD
/
YYYY
Submit
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This form was created inside of Pamlico County Schools.
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