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)
Student grade level
Name(s) of the person(s) making the referral
Your relationship to the student
Teacher or teacher assistant or staff at school
Parent/ family member
Other student / peer
What is the name of the class that the student has with you? If none, please state none.
What are the strengths of this student? Positive character traits?
Social / Emotional reason for referral (please check all that apply)
Social skills/ friends
Withdrawn / shy
Confidence / self-esteem
Uncooperative / defiant
Grief - Loss/ Death
Academic reason for referral (please check all that apply)
No academic reason
Please elaborate on what you have seen specifically in regard to what this student struggles with.
Please elaborate on any conversations that you have had with the student and/or the parents/guardians.
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?
The student needs to see Mrs. Erwin
Sometime this week
Any other comments or concerns?
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