GMS Counseling Referral 2017-18
Thank you for taking the time to complete this referral. Please complete this even if you think we are already aware.
Student name (First and last)
Your answer
Student grade level
Name(s) of the person(s) making the referral
Your answer
Your relationship to the student
What is the name of the class that the student has with you? If none, please state none.
Your answer
What are the strengths of this student? Positive character traits?
Your answer
Social / Emotional reason for referral (please check all that apply)
Academic reason for referral (please check all that apply)
Please elaborate on what you have seen specifically in regard to what this student struggles with.
Your answer
Please elaborate on any conversations that you have had with the student and/or the parents/guardians.
Your answer
If a miracle happened and this student came into school without this roadblock/ reason why you are referring them- what would change in the student? What would the student look like?
Your answer
The student needs to see Mrs. Erwin
Any other comments or concerns?
Your answer
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