School Counselor Referral Form for Parents & Teachers
This form is for parents and teachers referring a student. PLEASE NOTE, IF YOU ARE A STUDENT AND NEED HELP, PLEASE EMAIL MRS. BOST DIRECTLY AT THIS EMAIL:
or fill out the student form located on the school website or in your Google Classroom.
Your Name (do not enter student name here)
Best phone # for contacting you directly:
Relation to Child:
Name of Child's School
Messiah Lutheran School
St. Mary School
Reason(s) for referral (check all that apply)
Grief and Loss
Other reasons for referral (please state below)
Are you aware of any relevant medical history, such as medication, diagnosis, family history of mental illness, etc?
To the best of your knowledge, are any other services/organizations involved with this child or family?
Please provide any further information regarding this referral
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