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Social/Emotional Counseling Referral Form
If the student is in immediate danger of hurting themselves or hurting another student,
contact the counseling office at extension 7818 and DO NOT use this form.
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* Indicates required question
Student Name:
*
Your answer
Student Grade
Your answer
Referred By:
*
Your answer
Please check area(s) of concern that you have observed:
*
Family Concerns
Grief/Loss
Poor Peer Relationships
Poor Social Skills
Poor Self-esteem
Withdrawn
Anxious/Worried
Self-Control
Sadness
Frustration
Anger
Stress
Inattentive
Study/Organizational Skills
Work Completion
Other:
Required
Please describe your concern or provide other important information:
*
Your answer
Urgency
*
Choose
See student when available
See ASAP
Emergency (Please call counseling office at 7818)
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