Roberts School Counselor Referral Form
This form is confidential and will only be viewed by Roberts Middle School counseling staff.
What's the Date of Referral? *
MM
/
DD
/
YYYY
Time
:
Who is being referred? *
First Name, Last Name, Grade, ID#
Your answer
What is your relationship to the student? *
Please select one from the following list:
Reason(s) for Referral- Problems/Concerns related to: *
Please check all that apply:
Required
Additional Information: *
Give details about the situation; be very specific.
Your answer
Ideal time to see this student. *
What times would be best come get this student? If this is an emergency please call the office after answering NOW.
Your answer
Have you contacted parent/guardian about your concern?
If yes, please enter details in the the other field.
ACTIONS taken by the person referring this student, if applicable:
Your answer
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