Parent / Guardian Referral Form
A Professional School Counselor is available for students, parents, faculty and staff by appointment. Please call (417) 678-2251, stop by the Counseling Office, or email
to schedule an appointment.
I am requesting that the School Counselor talk with my child
URGENT - TODAY!
As soon as possible.
After the School Counselor and I talk.
Student Last Name
Student First Name
Student grade level
Relationship to student
Your phone number
Best time to contact you
My child's strengths include
My primary concern
*Check all that apply
Something's wrong but I don't know what
A loss (e.g. death of a person or pet, loss of a friendship, parents' divorce)
Relationships with friends/peers
Relationships with adults (parents/teachers)
Relationships with brothers/sisters
How my child is treated by others
Feelings of negativity, discouragement, self-doubt
Unhealthy or unsafe choices
Study skills, grades and schoolwork
Post-secondary options / Planning now for the future
Additional information regarding your concerns
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