Staff Referral Form 2020-2021
This form is for staff members to request counseling services for students. Any information shared in this form is for the use of the school counselor and will NOT be kept in the any cumulative files. If the basis for your referral is to report any abuse, neglect, or intent to harm, you are required to contact the Department of Children's Services at 877-237-0004. Thank you for helping us better serve our students.
Your last name, first name *
Student's Last Name, First Name *
Student's grade (number or letter only. Ex. K or 3) *
Which category best describes the need of your student?
Clear selection
Other reason for referral not listed.
Level of urgency *
Brief description of issue: *
Addition Helpful Information: Please answer as many as possible. Your answers will help me address the student's issues more comprehensively.
Have you spoken to the caregiver about this situation?
Clear selection
Caregiver contact comments:
Please note any interventions or strategies you have tried prior to referring:
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