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)
Date *
MM
/
DD
/
YYYY
Your child's name *
Your answer
Teacher's name *
Your answer
Grade *
Your name *
Your answer
Your relation to child(ren) being referred *
Your answer
Please check the characteristics which generally describes your child's needs and your concerns *
Required
Briefly describe the specific incidents that led to your referral *
Your answer
What ultimate goal do you want your child to achieve?/What do you want the end result of counseling to be? *
Your answer
How will you know/what will it look like when your child has reached this goal/result? *
Your answer
Check which actions have already been made to help your child make the needed changes in his/her behavior and/or emotional needs: *
Required
Briefly describe at least three positive strengths your child displays. *
Your answer
Your phone number where I can reach you to follow up after meeting with your child *
Your answer
Your email address where I can reach you to follow up after meeting with your child
Your answer
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