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Counseling Services Referral
Please fill out the form below if you would like to be contacted by a counselor or social worker regarding your student. You will receive a phone call or email from a counselor or social worker regarding this referral prior to staff speaking with the student.
* Indicates required question
Email
*
Record my email address with my response
Student Name:
*
Your answer
Referring Guardian Name:
*
Your answer
Reasons for referral (check all that apply):
*
Academic
Attendance
Basic needs (school supplies, hygiene products, clothing, food, etc.)
College/Career
Family issues that concern the student
Grief/Loss
Housing concerns/Homelessness
Peer conflict/bullying
Social Emotional/mental well-being
Other:
Required
Please provide a brief narrative in regards to each checked area of concern
*
Your answer
Preferred method of contact:
*
Email
Phone
Email address or phone number to reach you at:
*
Your answer
Send me a copy of my responses.
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