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Counseling Referral 24-25
Please send me a referral for your student you need to send to me.
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* Indicates required question
Students Name
*
Your answer
Room #
*
Your answer
The problem is
*
small (please come see me sometime this week)
Medium (please come see me within 2-3 days)
LARGE (ASAP)
What is wrong?
*
Needs a break
Sad
Behavior
Anxiety
Family
Social/Friends
Anger
Grief/ loss
Other
Just Checking in
Good things
Required
Explanation
Your answer
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