Parent/Guardian Counseling Referral Form
Please complete this form if you would like me to individually meet with your child(ren). Please note that I will meet with your child(ren) as soon as I can. In the event of an emergency, please call the main office (585-248-6311)
Your child's name
Your relation to child(ren) being referred
Please check the characteristics which generally describes your child's needs and your concerns
Body image concerns
Angry or aggressive
Homework not completed
Poor study/work habits
Difficulty making/keeping friends
Poor social skills
Briefly describe the specific incidents that led to your referral
What ultimate goal do you want your child to achieve?/What do you want the end result of counseling to be?
How will you know/what will it look like when your child has reached this goal/result?
Check which actions have already been made to help your child make the needed changes in his/her behavior and/or emotional needs:
School Counselor conference/communication
Received counseling outside the school setting
Discussion with the pediatrician
Briefly describe at least three positive strengths your child displays.
Your phone number where I can reach you to follow up after meeting with your child
Your email address where I can reach you to follow up after meeting with your child
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service