Counseling Referral Form 2019-2020
To be completed by a parent/guardian.
Email address *
Counseling Information
Counseling MAY be beneficial for students who struggle with:
Peer Relationships
Family Changes
Social Skills
...and a variety of other life situations....
Counseling Referral Procedure
1) Complete the online referral found on the St. Marcus website or contact Marianne Beyersdorf via phone (262-349-3733).

2) Marianne will collaborate with you about your concerns and discuss the options available for your student.

3) Marianne will complete a classroom observation and/or communication with Special Education/Deans/Directors about level of intervention needed and/or available for the student.

3) Communication/Collaboration with teacher regarding intervention plan & data tracking
*If individual counseling or small group intervention is decided upon:
a) Teacher may complete a referral as well (if applicable)
b) Corresponding permission forms will be sent home & need to be returned before counseling can begin
c) Strengths and Difficulties Questionnaire completed by teacher/parent/student (if applicable)
d) Marianne will coordinate counseling schedule in collaboration with classroom/student schedule & communicate with teacher/adviser.

4) Follow-up communication between the teacher, advisor, counselor, parent, and admin will be expected throughout the intervention.

*note: some steps may change depending upon severity and/or historical needs of an individual student

Never submit passwords through Google Forms.
This form was created inside of St. Marcus Lutheran School. Report Abuse