PHE 2017 Counseling Referral
Use this form to refer PHE students for Counseling Services
Student Name
Please provide the student's full name, first and last, including any nicknames.
Your answer
Referred by:
Please provide your full name and relationship to the student.
Your answer
How urgent is this issue?
Please rate this issue on a scale of 1 to 5,
I'm a little worried.about this student
I am afraid this student is in imminent danger.
Student's Grade Level
Teacher Name
Please provide the name of the student's current teacher if known.
Your answer
General area(s) of concern.
Please check all that apply.
Please tell me more about what has prompted you to refer this student:
Your answer
What type of services do you believe he/she needs at this time?
Please check all that apply.
Is there any relevant history or other information that the Counselor should be aware of?
Your answer
Does this issue require a very quick response from the counselor?
(If you check this box the Counselor will receive an immediate notification sent to her phone)
Email Address
Your answer
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