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School Counseling Student Referral Form
School Counseling Student Referral Form
Parents and Teachers- Please use this form to refer students for support with the School Counselor, during the 2023-2024 Academic School Year.
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* Indicates required question
E-mail
*
Your answer
Student First and Last Name
*
Your answer
Grade and Teacher
*
Your answer
Parent Name and Best Contact Phone
*
Your answer
Referred by
Parent
Teacher
Self
Other:
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Student lives with
Your answer
Reason for referral
*
Your answer
Please Check All that Apply
Chronic Absenteeism
Special Education
Foster Youth
Challenges/Concerns related to
Changes in behavior
Perfectionism
Grief/Loss
Anger/Aggression
Bullying
Peer relationships
Personal hygiene
Sexual acting out
Study skills
Fears
Easily distracted
Sadness
Fighting
Lying
Social skills
Always tired
Highly sensitive
Attendance
Nervous/Anxious/Worries
Self Image/Confidence
Withdrawn
Swearing/name calling
Disrespectful
Chews paper/pencil/hair
Personal boundaries
Destruction of property
Tardiness/Late
Taking things/Stealing
Motivation
Self harm
Defiant(refuses to do tasks)
Impulsive
Makes sounds
Family concern
Inattentive
Other:
What strategies have been tried to address concerns?
Your answer
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