Middle School Counselor Referral Form
Please complete this referral form if you have attendance, academic or social/emotional concerns regarding your child or student. Thank you!
* Required
Email address
*
Your email
Student last name
*
Your answer
Student first name
*
Your answer
Student grade
*
5th grade
6th grade
7th grade
8th grade
Your name
*
Your answer
Who is completing the referral?
*
Student
Parent
Teacher/Staff
What is the reason for referral?
*
Attendance concerns
Academic concerns
Social/Emotional concerns
Required
Is this your first time completing a referral form for the student?
*
Yes
No
What steps have already been taken?
Emailed student
Emailed parent
Called parent
Held Zoom meeting with student
Held Zoom meeting with parent
Other:
Please explain the reasoning behind the referral.
*
Your answer
Is there anything else you would like the school counselor to know at this time?
Your answer
Submit
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