NCA School Counseling Services 5th-8th: Confidential Parent Referral Form 2018-2019
Personal life circumstances, or the transition to a new school or a grade level, can make school overwhelming for some students. Depending on their maturity, skills, and ability, they may find it difficult to immediately meet the expectations of school without guidance and support. School counselors are here to help! We offer strengths-based Christian counseling, mentoring, coaching, and encouragement with the highest level of confidentiality at all times.

School counseling is intended to be short-term to help students identify problems, causes, coping skills, and develop goals to take appropriate action. Clinical counseling services or therapy are not provided at NCA. Through school counseling, I develop confidential relationships with students. This means that information gathered through meetings with students will be kept confidential unless given permission by student or there is a safety concern. If at anytime I feel that the student needs more extensive counseling or therapy, the student will be referred to outside resources.

Please fill out the following form if you would like to refer your child for counseling services.

Student's Name *
Your answer
Grade *
Referred by *
Your answer
Reason for Referral (Check all that apply): *
Required
Briefly describe the primary problem/concern: *
Your answer
Has the problem/concern been discussed at home? *
Has the problem/concern been discussed with the teacher? *
If yes to the above question, what was the response?
Your answer
When did the problem/concern begin? Within: *
Any physical concerns or medications related to the issue?
Your answer
Would like me to contact you prior to meeting with the student? *
Level of Concern- *
Additional Comments:
Your answer
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