Counseling Referral Form
Please complete form and send an email to lizs@pioneersprings.org stating that a form has been submitted or with a link to your form. Please allow 2-3 business days to schedule appointments and contact admin with immediate concerns and 9-1-1 for medical emergencies.
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Your name and email address
Student Name
Grade
Homeroom Teacher
Type of Referral
Clear selection
Reason for Referral (Check all that apply)
How is this interfering with the student's learning and/or classroom community?
Have you addressed the concern and asked if the student would like to talk to someone (required for 6-12th) Exp:" I have noticed ________ recently. Is there some way I can support you and/or would it be helpful to talk to someone?"
Clear selection
If you answered "no" to the question above please talk to the student and return to this form afterwards. If unable to do so, please explain here:
What is already in place to support the student in the classroom and/or at home? This could include behavior interventions, support team with parents, behavior plan with student, etc. Example: https://www.pbisworld.com/
Severity of problem (How much is presenting problem interfering with daily functioning?)
Clear selection
Is the student at risk of harming themself or someone else?
Clear selection
Have parents been notified?
Clear selection
Anything else you'd like to share:
Submit
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