Parent School Counseling Referral Form
Please take a few moments to complete this form describing the concerns you may have regarding your child. Parent contact may occur by phone, conference, during parent teacher conferences or email. Ms. Hall, your child's counselor can be reached via phone at 803-985- via e-mail at
Student Last Name
Student First Name
Parent/Guardian Last Name
Parent/Guardian First Name
What is your child's teaching team?
What is the best number to contact you?
Which of the following areas relate to your concern?
Dealing with Divorce (Family Changes)
Keeping Your Cool: Anger Management
What Now? (Coping with Loss & Grief)
I Feel Good: Self-Esteem
Please provide a brief description of your concern.
Please provide any interventions you've tried at home.
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This form was created inside of Rock Hill Schools.