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Hopewell Parent Referral Form
Hello Parents/Guardians!
You may use this form to request that your child visit with the school counselor. You are also welcome to send me an email at halpine@parkhill.k12.mo.us
or give me a call at 816-359-6868, should you want to discuss the situation more in depth.
Please note: If this is an emergency and someone is in danger, please call the school directly.
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* Indicates required question
Email
*
Your email
Name of person making the referral:
*
Your answer
Telephone number:
Your answer
Preferred method of contact:
*
Email
Phone call
Required
Name of child(ren) you are referring:
*
Your answer
Grade level:
*
Kindergarten
First
Second
Third
Fourth
Fifth
Required
Reason for referral:
*
Academic concern
Emotional concern
Social concern
Behavior concern
Required
Briefly describe the issue/why you would like your child to speak to the school counselor:
*
Your answer
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