7th Grade Student Referral Form 2019-2020
This form is for students 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 you report any abuse, neglect, or intent to harm, then the Department of Children's Services at 877-237-0004 will be contacted; as appropriate.
Your Last Name, First Name
Level of Urgency (Need)
Priority 1- Someone is in serious (physical) danger and I need adult help (Concerned for myself or someone else)
Priority 2- I need to talk to someone really bad! (Today or tomorrow)
Priority 3- I need to see you but it's not an emergency.
Priority 4- FYI- For Your Information (I want to let you know)
Which category best describes why you need to speak with me? (This helps me, help you...See examples below)
Personal/Social Matters - (Conflict/Drama)
Academic Support - (Grades)
Stress/Anxiety (Due to school or any other reason)
Family Change (move, divorce, separation, death, new sibling, etc...)
Other (Anything not listed above)
OTHER (Anything not listed above - Explain).
Tell me why you need to see me in detail based on what you choose above.
Have you talked to your parent/guardian about this situation?
HOW have you attempted to make the situation better?
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