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.
2. Last Name, First Name (Ex: Hansen, Emily)
3. Grade Level
4. My problem is... (check as many as you wish)
I'm concerned about my grades
I'm concerned about things at home
I'm trying to do better, but it's hard.
I'm feeling angry.
I'm feeling sad.
My friends and I are not getting along.
Someone is bullying me. (Also tell an adult immediately.)
I'm concerned about another student.
I am missing someone who has died.
I've been hurting myself (or thinking about it)--(Also tell an adult immediately)
I just need to talk.
5. Tell me a little bit more about why you need to see me.
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