Student Services Referral Form
Please use this form to refer students if you have a concern. Choose from the options below or write in your specific concern. ***Do NOT use this form if your concern pertains to suicide or abuse-you must report it to a counselor/admin directly***
Referring Staff Name
Nature of Concern
Check all that apply.
Behavior (this referral should NOT take the place of a formal discipline referral, if relevant)
General Mental Health
IEP or 504 Concern
Peer Conflict/Social Issue
Please include specific information about the concern you selected above.
A counselor will review the information provided and will respond accordingly- thank you for taking the time to refer a student in need!
Remember that issues related to Suicide or Child Abuse must reported directly to the appropriate resource as soon as possible. Please do not use this form to report suicide or abuse.
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