On-line Counseling Referral Form
Thank you for making a student referral. All referrals will be addressed within 48 hours of our receiving this form.
If an emergency exists please contact the counselors immediately through the front office (452-2226) or via email:
Dustin Clark (A-K) dclark1@fortsmithschools.org
Katie Mankins (L-Z) kmankins@fortsmithschools.org

For an EMERGENCY contact Safe School Helpline: 1-800-4-1-VOICE (800-418-6423) or call 911.
Email address *
MM
/
DD
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YYYY
Student Name, last-first *
Your answer
Grade
Name of person making this referral *
Your answer
Description of the student concern: *
(Concerns observed at school)
Required
Home Situation
Do you have personal information about any of the following?
Other information
Your answer
Submit
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