Counseling Referral 2023-2024

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Please complete as much information as possible. We will pull students based on time and severity. If a student is in CRISIS, please do not leave the child unattended. Escort the student, buzz the front office, or call the Counselor's office for the Counselor to come to your room ASAP. You must still complete the referral form as soon as possible. Any referrals done after school hours will be reviewed during school hours. Thank you- Counselor team!

Email *

Date: *

YYYY

Referred by: (Please state if it is a student self-referral)
*

Student (First and Last Name, ID #, and Grade Level): *

Reason for Referral:
*

Student Opted Not To Share

Low Self-Esteem/Shy/Withdrawn

Sudden change in grades

New student having difficulties adjusting

Difficulty Making Friends/Poor Social Skills

Problems with Friends

Illness/death in the family

Divorce/separation/difficulties with blended family

Behavioral Challenges in Classroom Setting

Anxiuos/worried

Other:

Required

Comments/Concerns (Elaborate from above-Please let us know as much information as possible regarding the referral):
*

Has the parent/guardian been contacted regarding this concern?
*

Yes

Parent/Guardian made the request

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