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Counseling Request Form
Please fill in all required information and check as many boxes as necessary regarding reasons for referral. Any additional information you choose to provide would be very helpful as well!
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* Indicates required question
Email
*
Your email
Student Name:
*
Your answer
Grade:
*
6
7
8
Freshman
Sophomore
Junior
Senior
Required
Date:
*
MM
/
DD
/
YYYY
Referred by:
Your answer
Reason for counseling referral:
Motivation
Bullying (Either being bullied or initiating bullying)
Divorce
Anger; Fighting; Aggression
Confidence
Stress
Peer Relationships
Change in behavior/mood
Personal hygiene
Social skills
Excessive absences/tardies
Academic concerns (Perfectionist? Withdrawn? Inattentive?)
Dishonesty/Lying
Depression/Sadness/Grief & Loss
Fear/Anxiety
Other:
Additional information concerning the referral:
Your answer
Has a parent/guardian already been contacted regarding these concerns?
Yes
No
This referral:
is an emergency
is a non-emergency
Best time to meet with student:
Your answer
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