Darnall Charter School: Referral to School Counselor

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STUDENTS: If you would like to speak to your school counselor about ANY concerns then fill out this form and we will contact you as quickly as we can!

PARENTS: Please complete the referral form if you have concerns and would like to refer your child to counseling. Your child's school counselor will contact you upon receiving the form to discuss counseling options.

Mrs. Vallejo and Mrs. Tomboc (TK - 8th Grade)

If this is an immediate mental health need, please contact The Access & Crisis Line at 1-888-724-7240 (7 days a week, 24 hours a day).

Who is completing this form? *

A parent/guardian

A student

Other:

First Name (Parent/Guardian) *

Last Name (Parent/Guardian) *

First Name (Student) *

Last Name (Student) *

Grade level of student? *

How do you prefer to be contacted? *

Phone

Dojo

Required

What is a phone number where you can be reached? *

What is your email address?

Check each category that you would like to talk about with your school counselor. *

Coronavirus (COVID-19)

Divorce/Families in Transition

Study Skills and Goal Setting

Anger Management

Friendship Skills

Conflict Resolution/Problem Solving

Self-Confidence/Self-Esteem

Sibling Rivalry/Family Conflict

Stress Management/Anxiety

Self-control/ making good choices

Other

Required

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