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23-24 Counseling Services Referral Form- -Formulario para referir a servicios de consejería
Please fill out this form to refer your student to counseling services at school.
Por favor llene este formulario para referir a su estudiante a servicios de consejería.
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Email
*
Your email
Disclaimer
If concern is an emergency please call 911 or Ventura County Crisis Response Team 1-866-998-2243-
Si su precupacion es una emergencia por favor llame all 911 o al Equipo de Intervencion del Condado de Ventura 1-866-998-2243
Student's name- Nombre del estudiante
*
Your answer
Student grade- Grado del estudiante
6th
7th
8th
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Parent/ Guardian name - Nombre del padre o guardian
*
Your answer
Parent/ Guardian phone number- Numero de telefono de padre o guardian
*
Your answer
Reason for referral- razón por la que esta refiriendo al estudiante a consejería
*
Attendance/ Falta de asistencia a la escuela
Academics/ Académico (grados bajos, falta de motivación para hacer trabajo escolar)
Social Emotional ( sadness, anger, anxiety, etc.)/ Emocional ( tristeza, enojo, ansiedad)
Other:
Required
Please let us know why you are referring your student to school counseling services- Por favor déjenos saber por que esta refiriendo al estudiante a servicios de consejería
*
Your answer
A copy of your responses will be emailed to the address you provided.
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