Student Counseling Referral Form
Please complete this if you have a concern(s) with a classmate/friend and would like to refer them to the counseling office for assistance in the areas of social/emotional, academic, or career development. If you have questions see Becky Whitmer (HTC School Counselor) or Bridget Zabel (HTC Resource Educator- School Counselor in Training).
Student Name *
Your answer
Grade Level *
Your answer
HTC Program *
Your answer
Sending School *
Your answer
Referred by: (Your Name) *
Your answer
Areas of Concern-Personal/Social Development (Check all that apply) *
Required
Areas of Concern- Academic Development (Check all that apply) *
Required
Areas of Concern- Career Development (Check all that apply) *
Required
Reason for Referral *
Your answer
Priority *
See when possible
See right away- Emergency
Additional Comments:
Your answer
Submit
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