CCS Counseling Referral
To be completed by parent, guardian, teacher, or student.
Email address
Student being referred
Your answer
Grade
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Homeroom teacher
Your answer
Referred by (your name)
Your answer
Your phone number
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Reason for referral (check all that apply)
Required
Briefly describe the primary concern.
Your answer
Has any action been taken at home or school? If so, what was the response?
Your answer
Any physical or medication concerns with the issue?
Your answer
additional comments
Your answer
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