Parent/Guardian form: Counseling Services

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Student Name: *

Student's Teacher *

Parent/Guardian Name *

Parent/Guardian phone number *

Academic Referal (check as many as apply)

Attendance

Grades

Organization

Motivation

Homework

Study skills

Other

If you marked "other" please explain:

Social/Emotional Referal (check as many as apply)

Social skills/friends/conflict with another student or group of students

Anger or aggression

Withdrawn/Shy

Difficulty following directions

Participation in class

Uncooperative/Defiant

Family Issue

Grief/loss

Anxiety

Personal hygiene

Other

If you marked "other" please explain:

Interventions I have tried:

I would like the counselor to know this additional information:

My child needs to see you *

Right away: this is very important!

As soon as possible.

When you have time.

I would like you to see my child *

one time

in a small group

for 6 individual counseling sessions

I would like the school counselor to call me to discuss my student

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This form was created inside of Keyes Union School District.