School Counseling Referral Form - Parent/Guardian

Thank you for reaching out to our school counseling program. Parents and guardians may use this form to request support for their child or to share a concern with the school counselor.

After this form is submitted, the school counselor will review the information and determine the appropriate next steps. Depending on the concern, the counselor may contact you, meet with your child, consult with school staff, or provide additional resources.

Please note: This form is not monitored continuously and should not be used for emergencies or situations requiring immediate assistance. If there is an immediate safety concern, please follow your school’s emergency procedures or contact appropriate emergency services.

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Student's First and Last Name *
Student's Grade *
Student's Teacher
Parent or Guardian's Name *
Relationship to Student *
Preferred Phone Number
Email
What is the best way for Mrs. Froning to contact you?
Clear selection
What would you like support with? *
Required
Please tell me a little more about your concern. *
How long has this been a concern?
Clear selection
How much is this concern currently affecting your child at school or at home?
Very Little
A Great Deal
Clear selection
Have you already discussed this concern with your child's teacher or another school staff member?
Clear selection
Is there anything Mrs. Froning should know before speaking with your child?
What would you most like your child to receive help with?
Would you like Mrs. Froning to contact you before meeting with your child?
Clear selection
Please acknowledge the following: *
Required
Submit
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