Secondary School Counseling Referral

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Secondary School Counseling Referral - Parent Form

*If this is an emergency, please get immediate assistance*

Privacy and Confidentiality Disclosure

As a parent or guardian, please trust that the GIS Counseling Team will prioritize the wellbeing of your child.

Your child must be aware, and trust that, what is shared with their counselor will stay with the counselor unless they give permission to share information, OR if the counselor suspects the child is in danger of being hurt by others, hurting themselves, or hurting others.

Student's Full Name *

Student's Grade *

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

Parent/Guardian Name

Parent/Guardian Email

Parent/Guardian Contact Number

Reason for the referral

Emotional Well-being (low mood, anxiety/stress, etc.)

Anger Management

Academic concerns

Healthy Habits

Family Environment

Grief and Loss

Trauma

Other:

Clear selection

Please provide further information regarding your referral.

Any relevant history you would like us to know about?

Is the student aware of the referral?

Yes

Clear selection

What is the best time to reach you over the phone?

Please note

School based counseling address concerns that affect the child in school and is short-term.

The school counselor is not a therapist and does not make diagnoses. (A list of professional mental health providers can be provided upon request)

I understand

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