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Counseling Referral form (external source)
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* Required
Student referring:
*
Your answer
Current date:
*
MM
/
DD
/
YYYY
Name of person making referral:
*
Your answer
Relationship to student:
*
Parent
Relative
Friend
Other
Description of issue:
*
Your answer
Urgency level:
*
1 - Low
1
2
3
3 - High
Thank you for your concern and submitting this form. It will be directed to our Counseling dept immediately.
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