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.
Referring staff member's full name
Reasons for Referral (check all that apply)
Behavior in Class
Bullying / Target
Bullying / Perpetrator
Divorce / Family Change
Lack of Motivation
Low: a student has a minor concern that can wait to be addressed.
Moderate: a student has a concern that needs to be addressed in 3-4 days.
Critical: a student has an important concern that needs to be addressed in 1-2 days.
Emergency: a student is at risk to self or others and needs to be seen IMMEDIATELY (possible abuse, neglect, threat to self or others)
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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This form was created inside of Tishomingo County School District.