School Counseling Referral Form

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Please use this form to refer a student to the School Counselors. Students signing up to see a school counselor for non-urgent matters will be seen in the order in which requests are received.

Email *

Student's Name (first and last names) *

Student's Grade

9th

10th

11th

12th

Clear selection

Who is making the referral? *

Student

Staff Member

Parent/Guardian

Name of Referring Staff Member

Counselor

Mrs. Cole (last names beginning with letters A-D & S-Z class of 2029-2030 letters A-K)

Mrs. Collins-Cardona (last names beginning with letters E-R class of 2029-2030 letters L-Z)

Ms. Suppi (SAC)

Clear selection

Academic Reason for Referral (Check all that apply)

Grades

Absences

Homework

Classwork

Organization

Study Skills

Test/quiz scores

Other:

Graduation Planning

College Application Process

PSAT/SAT/ACT

Community College

Scholarships

Military

Other:

Personal/Social Reason for Referral (Check all that apply)

Self-esteem

Family concern

Anxiety

Withdrawn

Peer relationships

Motivation

Loss/grief

Inattentiveness

Other:

Additional Concerns or Information

Submit

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