Counselor Recommendation Form
Please answer the following questions to the best of your knowledge. Your answers will be kept confidential and will not be shared with the student or parents.
Student Last Name *
Your answer
Student First Name *
Your answer
Counselor Name *
Your answer
Which of the following could be identified as the student need (mark all that apply)?
Academic Functioning (Please rate the student) *
Lowest
Highest
Comments regarding academic functioning:
Your answer
Social Skills *
Lowest
Highest
Comments regarding social skills:
Your answer
Maturity *
Lowest
Highest
Comments regarding maturity:
Your answer
Family Situation *
Lowest
Highest
Comments regarding family situation:
Your answer
Does the student currently receive any of the following services? *
Are there any safety concerns/considerations that we should know about including threat or lethality assessments, child abuse reports, behavior plans, etc.? *
If yes, briefly describe. Please also include the best person to contact on your staff to receive further information.
Your answer
Has the student had attendance issues? *
Has the student had behavior issues? *
If yes to attendance or behavior issues, please explain.
Your answer
Thank you! If you have any additional information please provide it below.
Your answer
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