16-17 - Counseling Referral Form WCCS
Use this form to refer a student to the school counselors. If the referral is in any way related to self harm, suicide or any type of abuse, speak to a counselor or administrator in person after completing this referral.
Staff Member Completing Referral (Last Name, First Name) *
Your answer
Student's Name (Last Name, First Name) *
Your answer
Student's Grade Level
Which counselor is this referral for? *
Required
Academic Concerns
Personal/Social Concerns
Attendance Concerns
Situational Concerns
Briefly describe your concern(s) in the space below:
Your answer
The level of your concern is: *
Required
Remember: If the referral is in any way related to self harm, suicide or any type of abuse, speak to a counselor or administrator in person after completing this referral.
Your answer
Submit
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