6th and 8th Grade STUDENT Referral (2019-2020)
This form is CONFIDENTIAL. Only your counselor, MRS. Kersten, will see this.

If you are feeling like you want to harm yourself or someone else, TELL AN ADULT IMMEDIATELY and come to the counseling office.

If you are concerned about the IMMEDIATE safety of another student, TELL AN ADULT IMMEDIATELY.

All other concerns can be reported using this form.

This referral will only be seen by Mrs. Kersten during my HMS office hours Mon. -Fri. , 7:10 - 2:30.
1. Date *
MM
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DD
/
YYYY
2. Last Name, First Name (Ex: Hansen, Emily) *
Your answer
3. Grade Level *
4. My problem is... (check as many as you wish) *
Required
5. Tell me a little bit more about why you need to see me.
Your answer
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