Staff Referral Form 2018-2019: Jared Voelker 7th Grade
This form is for staff members to request services for students. Any information shared in this form is for the use of the school counselor and will NOT be kept in the any cumulative files. If the basis for your referral is to report any abuse, neglect, or intent to harm, you are required to contact the Department of Children's Services at 877-237-0004. Thank you for helping me better serve our students.
Your last name *
Your answer
Your first name
Your answer
Student's Last Name *
Your answer
Student's First Name *
Your answer
Student's grade (number or letter only. Ex. K or 3) *
Your answer
Reason for referral: Check all that apply *
Other reason for referral not listed.
Your answer
Level of urgency *
Brief description of issue: *
Your answer
Addition Helpful Information: Please answer as many as possible. Your answers will help me address the student's issues more comprehensively.
Caregiver Information: Student lives with
Have you spoken to the caregiver about this situation?
Caregiver contact comments:
Your answer
Has the caregiver requested that I meet with the student?
Please note any interventions or strategies you have tried prior to referring:
Your answer
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This form was created inside of Knox County Schools. Report Abuse - Terms of Service