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Parent Referral Form
Use to refer your student to the school counselor
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* Indicates required question
Student Name (Last name, First Name)
*
Your answer
Advisory Teacher (If known)
Your answer
Parent/Guardian Name
Your answer
Academic Reason for Referral (Check all that apply)
*
Attendance
Underachievement
Study skills
Homework/projects
College/Career
Scheduling Questions
None of these
Other:
Required
Social/Emotional Reason for Referral (Check all that apply)
*
Anger Managment
Social Skills/Friends
Negative Attitude
Withdrawn/Shy
Confidence/Self-esteem
Anxiety
Uncooperative/Defiant
Family Conflict
Adjustment
Grief-Loss/Death
Personal Hygiene
None of these
Other:
Required
What level is your concern?
*
Level 1-Requesting help on coping skills or input from an adult.
Level 2-It is a question about a class or friendship struggle.
Level 3-It is urgent but not an emergency. Student is experiencing anxiety, sadness, or other feeling.
Level 4-The student or friend is in crisis (suicidal ideation, self-harm, panic attacks or feeling unsafe about going home)
He/She needs to see me...
*
RIGHT AWAY!!
Sometime today
Sometime this week
Comments (anything that you think will be helpful to me)
Your answer
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