Referral Form: Parent '22-'23
School Counseling is a short-term service delivered to individuals or groups to help students function more effectively in the classroom and with their peers. The relationship between a student and their counselor carries communication privileges and rights to confidentiality. Any information shared by your student will be kept confidential. There are times when students divulge information that I feel should be shared with parents. I will encourage them to do so or request permission to discuss the matter with a parent or guardian myself. I will do this anytime I feel it is in the best interest of your student. There are also several situations in which I am required by law to share details of a counseling session with the appropriate authorities. 

Jenny George, PPS, APCC9636
School Counselor

* school counseling is not on-going mental health therapy. For serious concerns please contact the school counselor for outside counseling resources. 

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Your first and last name AND relation to student: *
Student Name: *
Student Grade: *
What are your concerns:  (You can select more than one.) *
Briefly describe your concerns: *
Please share any interventions (i.e. seeing a counselor outside of school, behavior chart, etc.) you have already put in place, and whether they were successful or not.  If none, then write NA *
Please list 3 or more strengths your student has: *
Please provide the best number and email to contact you with: *
Anything else you want to share?
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