Parent/ Guardian: School Counseling Request Form
This form is only for the Parents/ Guardians to refer their child to the school counselor, Ms. Boccella
Please be as thorough as possible.
If you have any questions or concerns, please email me at
If this is an emergency, please contact the main office directly.
Moderate (Schedule a meeting with your child when available)
High (Meet with your child ASAP)
Have you contacted the student's teachers about your concerns?
Reason for Referral
If you chose Emotions/ Mood, please check all that apply below.
Low Self-Esteem/ Negative Self-Talk
Angry/ Low Frustration Tolerance
If you chose Behaviors, please check all that apply below.
Hyperactive/ or inattentive
If you chose School Concerns, please check all that apply below.
Frequently Late or Absent
Poor Memory and/ or Often Confused
Sudden Change in Performance
If you chose Relationship, please check all that apply below.
Poor Social Skills
Few or no friends
Other Concerns, please check all that apply.
Illiness/ Death in Family
Interventions that you have used, please check all that apply below.
Consulted with Another Professional
Conferenced with Administration
Conferenced with Teachers
Clarify Concerns and Provide Any Background Information you feel will be of assistance.
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This form was created inside of Holy Cross School.