Iuka Elementary: Teacher Referral Form for School Counseling Services
The counselor will contact the student within two school days of receiving this referral. If this referral is urgent or you are concerned for the safety of this student, please contact the school counselor or office immediately.

Thank you for your referral! If this is a paper referral, please place in the counselor's mail box.

Mrs. Shea
Referring staff member's full name *
Email address *
Student Name: *
Date: *
Grade *
Reasons for Referral (check all that apply)
Concern Level: *
Any Other Specific Information:
Are parents/guardians aware of your concerns? *
If parents/guardians are unaware of your concern, why?
When is a good time to pull this student from the classroom? *
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