2019-2020 HESD School Counseling Services Referral Form
Thank you for taking the time to complete the referral form. The more information you can provide me regarding your concerns the better I can support you and the student. If you prefer, you may submit a paper copy instead and put it in my box.

Once I receive this form, I will be in contact with you regarding potential services. If ongoing services are needed, I will provide permission to parents/guardians.

Please keep in mind that:
School Counseling is brief and solution focused, typically lasting 6-8 sessions.
Parent permission is required for all counseling services.
Not all students referred will receive school based services.

If you have any questions regarding this form or about services offered through the counseling program, please do not hesitate to ask me!
Today's Date *
Your answer
Teacher *
Your answer
Room # *
Your answer
Student Name *
Your answer
Birth Date *
Your answer
Grade *
Your answer
Parent Name *
Your answer
Phone Number *
Your answer
Referred by (if different from classroom teacher):
Your answer
Moods/Behaviors
Please check all that apply
School Concerns
Please check all that apply
Relationships
Please check all that apply
Home Concerns
Please check all that apply
Reason for Referral (please be as specific as possible): *
Your answer
Intervention taken prior to referral *
Please check all that apply
Required
Please provide specifics from your responses above:
Your answer
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