On-line Counseling Referral Form - Parents
Thank you for making a student referral. Please be sure to rate the urgency of the issue on this form. If an emergency exists, please contact me immediately through the front office.
Please Rate the Urgency of this Issue
1-5 = Counselor will see this week 6-10 = Counselor will see within 2 school days of receiving referral
1 = A student that is turning in homework inconsistently
5 = A friendship or bullying issue that is negatively affecting the student, however the student does not feel directly threatened or in danger; A family situation (such as divorce) to which the student is aware, but not extremely distraught.
10 = A student that is extremely upset or distraught for any reason such as being threatened by another student, experiencing a loss, suicidal ideation, self-harm, alleging abuse by a caretaker, etc
** If you selected 8-10 please see/contact the counselor immediately and advise about the issue. **
Urgency of Issue
Student Name, last-first
Name of person making this referral
Have you contacted teacher regarding this concern?
If yes, what was the outcome of your teacher contact?
Description of the concern
Concerns observed at home. Please check all that apply.
Age inappropriate talk/actions
Disrespectful to adults
Disrespectful with peers
Frequent visitor to clinic
Inadequate social skills
Rejected by peers
Sleeps in class
Relationship to Student
Select any that apply.
death in family
parent has new partner
other please list below
Send me a copy of my responses.
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This form was created inside of Franklin County Schools.