Parent, Teacher, or Guardian Referral to the Counselor
This form is to be completed by a parent, teacher, or guardian when concerns arise that may warrant the need for counseling services by the BJES Counselor.
Parent, Teacher, or Guardian Completing Form:
Homeroom Teacher's Name:
What are your concerns?
Struggles with School Skills (organization, studying, academics)
Struggles to Get Along with Peers
Gets into Trouble at School (class disruptions, bullying, lying, defiance, please explain below)
Has had a Traumatic Event Occur (death in family, divorce, move)
Please explain concerns above if applicable:
Is your child currently receiving outside counseling services?
Would you like to be contacted before the counselor sees your child?
Is your child's teacher aware of your concerns?
Any Additional Information:
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