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2025-2026 Harlem Counselor Referral
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Email
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Record my email address with my response
Student Name
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Your answer
Grade
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Your answer
Person Making Referral
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Your answer
Reason for Referring Student
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Celebration
Absenteeism
Physical Complaints
Peer Relationships
Family Concerns
Self-Concept
Classroom/Academic Concerns
Suicide Threat (NOTIFY AN ADMINISTRATOR)
Self-harm (NOTIFY AN ADMINISTRATOR)
Change in attitude
Behavior Concerns
Bullying/Victim
Personal Hygiene
Grief
Other:
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Additional Comments
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