Guidance Counselor Referral Form

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Guidance Counselor Referral Form

This form should be used by teachers to refer students in need of support or intervention to a guidance counselor. Teachers must make multiple attempts of contact with a legal guardian and document that outreach in Skedula as an anecdotal before using this form.

See School Counselor or AP Crea with questions.

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* Indicates required question

Email *

Your email

Date: *

MM

/

DD

/

YYYY

First name of student being referred: *

Your answer

Last name of student being referred: *

Your answer

Student OSIS #: *

Your answer

Student’s Guidance Counselor name: *

Your answer

Reason for Referral: *

Your answer

Steps already taken: *

Your answer

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