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School Counseling Referral Form (Escuela Consejeria Referencia) John C. Fremont Elementary School
2025-2026
School Counselor, Melissa Juarez
559 992-8882 ext. 3237
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* Indicates required question
Date (Fecha):
*
MM
/
DD
/
YYYY
Student Name (Nombre del Estudiante):
*
Your answer
Referral Submitted By (Referencia presentada por):
*
Your answer
Grade (Grado):
*
Choose
2nd Grade
3rd Grade
Teacher (Maestro):
*
Choose
2nd F-2 Puga
2nd F-3 Martin
2nd F-4 Morris
2nd G-2 Welsh
2nd G-3 Perez
2nd G-4 Early
2nd H-1 Gobel
2nd H-2 Lerma
2nd H-3 Paulo
2nd H-4 Ramirez
3rd D-2 Wright
2nd/3rd D-3 Padilla
3rd D-4 Crane
3rd E-2 Fierro
3rd E-3 Becerra
3rd E-4 Lopez
3rd K-3 Goldsworthy
3rd K-4 Toste
3rd K-5 Bartron
3rd K-6 Bochman
3rd K-7 Cardona
Reason(s) for referral (Razones para la referencia):
*
Absenteeism (Absentismo)
Adjustment (Adjustamiento)
Aggression (Agresion)
Bullying/Bullied (Acosada)
Divorce (Divorcio)
Fears/Anxiety (Miedos/Ansiedad)
Loss/Death (Perdida/Muerte/Duelo)
Motivation/Attitude (Motivacion/ Actitud)
Peer Relations (Relaciones de companeros)
Self Esteem (Autoestima)
Social Skills (Habilidades sociales)
Withdrawn/Sadness (Retirado de los de mas)
Other:
Required
Details (be more specific about your reason(s) for referral (Detalles para referencia):
*
Your answer
Parent: Have you made contact with school staff regarding concern?
(Padres, se han puesto contacto con la escuela con respecto a la preocupacion?
Teacher: Have you contacted parents?
Please share interventions that you are using.
*
Your answer
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