Counseling Request

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Counseling Request

Hello!

Please complete the form below to initiate a referral for a student to receive counseling services from me in the school setting. My timeline for providing support typically ranges from 6-8 weeks (may be shorter or longer) with opportunities to communicate with you to discuss progress in order to make sure that emotional needs are being met and/or skills are being generalized in the school and/or home environment. As we collaborate together, we may decide that the student needs more intensive support than I am able to provide in the educational environment in order to support their well-being. Therefore, we will discuss resources together that are available in the area and may benefit the student. I am looking forward to working with you.

Kindly,
Sara Cameron

Date of Request

YYYY

Your Name

Student Name

Student Grade

Preschool

Kindergarten

First

Second

Third

Fourth

Fifth

Transitional Kindergarten

Clear selection

Reason for Referral

Check-In

Individual Counseling

Group Counseling

Clear selection

Areas of Concern

Self-Confidence

Behaviors related to Anxiety

Behaviors related to Depression

Grief Support

Positive Self-Talk

Goal Setting

Calming Strategies

Relationships with Peers and/or Adults

Overall School Performance

Family Dynamics

Other

If you marked 'other,' please explain what you notice to be the area(s) of concern:

If you would like to describe the area(s) you marked above, please provide some insight of your observations below:

Is there anything else that I can do to support this student and/or family at this time?

Submit

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This form was created inside of Kalama School District.