Cottage Hill Counseling Referral

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Please fill out this form to make a referral to school based counseling. You may contact Michele Neeb, mneeb@prsd.us or 530-205-5376 with questions. Students that participate in small groups will work with one to three other students during their P.E. time . Teachers will be contacted with scheduling information prior to a group starting.

Name of person making referral, relationship: *

Last name of Teacher

First 3 letters of first and last name of student

e.g. AbcDef

Grade Level *

Kinder

First

Second

Third

Fourth

Fifth

For Teachers: Cumulative Record Review Complete *

Yes

N/A

Academics/Grades *

Mastery of standards

Meets standards

Average to below grade level standards in one to two subjects

Below grade level standards in three or more subjects

Unknown

Primary Concerns *

Conflicts with peers

Academics

Attendance

Repeated behavioral problems

Emotional regulation

Referral information

Required

My student would best benefit from groups about: *

Social skills

Emotional regulation

Goals, grades, and organization

Behavior

Family Contact with dates

Does the student have a 504 plan? *

Yes

List 504 accommodations if applicable:

Does the student have an IEP? *

Yes

Has the Case Manager been contacted? *

Yes

N/A

The Parents/Guardian have been notified of the referral? *

Yes

All school staff are mandated reporters.

Dear Parent(s)/Guardian(s),

This referral is for school based guidance and counseling interventions. These services are designed to help students learn and practice skills that are important in the school environment as well as working with others. Many of the activities will focus on helping students learn to regulate their emotions in a safe, healthy manner, build positive social skills and self confidence and constructively manage relationships and conflict.

Services generally meet once a week during school hours. The duration will depend on continual assessment of what is needed, but usually last between 6 weeks and 1 trimester. We will be working with the classroom teacher to select a time so the students will not miss core instruction.

Because counseling is based on a trusting relationship between counselor and the student, the counselor will keep information shared by the student confidential except in certain circumstances:

1.The student reveals information about hurting himself/herself or another person.

2. The student or another person may be in physical danger.

If you have questions or concerns, please contact Michele Neeb at (530) 205-5376 or mneeb@prsd.us.

I am the guardian and have read the disclosure. I give consent for my child to participate.

I am a staff member and made the referral.

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