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.
Email address *
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

Examples:
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 *
Not Urgent
Very Urgent
Date *
MM
/
DD
/
YYYY
Time
Time
:
Student Name, last-first *
Your answer
Teacher *
Your answer
Grade *
Name of person making this referral *
Your answer
Have you contacted teacher regarding this concern? *
If yes, what was the outcome of your teacher contact?
Your answer
Description of the concern *
Concerns observed at home. Please check all that apply.
Required
Relationship to Student *
Home Situation
Select any that apply.
Other information
Your answer
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