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:
carolmbost@gmail.com
or fill out the student form located on the school website or in your Google Classroom.
* Required
Email address
*
Your email
Your Name (do not enter student name here)
*
Your answer
Best phone # for contacting you directly:
*
Your answer
Relation to Child:
*
Parent
Teacher
Principal
Self
Other:
Student Name
*
Your answer
Name of Child's School
Choose
Messiah Lutheran School
St. Mary School
Parent/Guardian Name
*
Your answer
Grade
*
Your answer
Reason(s) for referral (check all that apply)
*
Motivation
Parental separation/Divorce
Fears/Worries/Anxiety
Stressed
Friendship problems
Anger/Agitation
Grief and Loss
Depression
Withdrawn
Sadness
Suicide/Self-harm
Behavioral Concerns
Parental Concerns
Academic Concerns
Other:
Required
Other reasons for referral (please state below)
Your answer
Are you aware of any relevant medical history, such as medication, diagnosis, family history of mental illness, etc?
Your answer
To the best of your knowledge, are any other services/organizations involved with this child or family?
Your answer
Please provide any further information regarding this referral
Your answer
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