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CAES School Counseling Referral 2023-2024
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Parent/Teacher Referral for Counseling Services
Student Name
*
Your answer
Person filling out this form
*
Parent
Teacher
Other
Teacher
*
Your answer
Date
*
MM
/
DD
/
YYYY
Reason for referral (check all that apply)
*
Aggression
Dramatic change in behavior
Bullying- target
Bullying- perpertrator
Self-Injury (cutting, biting, head-banging, etc)
Daydreams/ Fantasizes
Anger Management
Physical fighting
Stealing
Lying
Sexualized behavior
Difficulty in peer relationships
Social skills
Family concerns
Change in family dynamics
Cries easily/ often for age
Rigid/ Inflexible
Self-image/ Self-esteem
Grief and loss
Always tired
Sadness
Worried/ Scared
Defiant
Impulsive/ Hyperactive
Inattentive/ Distracted
Disruptive
Withdrawn
Anxious/ Nervous
Drastic mood shifts
Lacks motivation
Work completion
Organizational skills
Personal Hygiene
Suicidal ideation
Other:
Required
Explanation: Please explain the behaviors checked above, and any additional information the would be helpful.
*
Your answer
Teachers, When is a good time to pull the child from the classroom? (Please keep in mind that lunch and recess are not ideal)
Your answer
Parents, What is a good phone number where you can be reached for follow up?
Your answer
Parents, What is a good email address for you to be reached for a Zoom Link (if needed).
Your answer
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