EKCE Staff Referral 19-20
This form is for staff members to request counseling services. Any information shared in this form is for the use of the school counselor and will NOT be kept in the any cumulative files. If the basis for your referral is to report any abuse, neglect, or intent to harm, you are required to contact the Department of Children's Services at 877-237-0004. Thank you for helping me better serve our students.
Your last name, first name *
Your answer
Student's Last Name, First Name *
Your answer
Student's grade (number or letter only. Ex. K or 3) *
Your answer
Which category best describes the need of your student?
Other reason for referral not listed.
Your answer
Level of urgency *
Brief description of issue: *
Your answer
Addition Helpful Information: Please answer as many as possible. Your answers will help me address the student's issues more comprehensively.
Have you spoken to the caregiver about this situation?
Caregiver contact comments:
Your answer
Please note any interventions or strategies you have tried prior to referring:
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Knox County Schools. Report Abuse - Terms of Service