2025-2026 Counseling Referral
This form is to be filled out by teachers and staff when you have a concern about a student and/or if you call a counselor to help you with a student. If there is Student SELF-INJURY or SUICIDAL Ideation, immediately located counselor/admin forgo the form until asked to report, and stay with student.

If you have further questions, please contact: 
Ms. Bennett, 1703 
Mrs. Quadres, 1716 

If you are reporting BULLYING, BULLYING behavior, HARASSMENT,  or THREATS please speak with an administrator: Dr. Thomas or Mrs. Thakkar
Email *
IMPORTANT CHANGE
EVERYTHING on this form is subject to subpoena. Do NOT include detailed information. Be very measured - keep personal notes. We will reach out if we need clarification or please speak with your team, admin or counselors where appropriate. We do not want these details to compromise the campus' abilities to help our students.

If there is something, brief that is not covered above, you may include it here. Keep notes for yourself.
Your Last Name: *
Student INITIALS (Do not put their names). *
Grade level *
If a code was called, what color was it? *
Required
General Reason *
Required
Have you contacted parent/ guardian/ caregiver? (if yes, write who you contacted in follow up question) *
I read the important change about additional details. I will reach out to the counselor assigned or administrator with details about the situation. *
A copy of your responses will be emailed to .
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