WWES Counseling Referral Form (23-24) - Teachers & Staff
Thank you for taking the time to share information about a student you think could benefit from counseling services! Please add as many details as possible and submit this form.

NOTE: This referral is confidential. The school counselor will provide acknowledgement of receipt and status of this referral within 3 working days.
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What is today's date? *
MM
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DD
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YYYY
Student's Name (First & Last Name) *
Student's Grade *
Student's Gender *
Teacher's Name *
Referred by (name & relationship to student): *
Reason for Referral: *
Required
Please describe your reason(s) for this referral and any additional concerns or information: *
Steps taken to address the concern (i.e., what interventions are in place?): *
Required
Please rate the severity of this referral on a scale of 1 to 10 by how serious (immediate) this problem is:   *
Less Serious
Very Serious
Has this issue and/or the possibility of counseling services been discussed with the student's parent(s)/caregiver(s)? *
Outcome of Contact (parental/caregiver response or action):
Please list this student's strengths (i.e., creativity, resiliency, courage, positivity, student likes, etc.):
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