2023-2024 SCES School Counseling Referral

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This form is to refer a student to see the school counselor for NON-CRISIS concerns. For crisis intervention needs (suicidal ideation, threats to others, students in distress, etc) please contact the main office IMMEDIATELY for counselor and/or admin to respond.

Student's Name: *

(LAST Name, FIRST Name)

Grade Level: *

Homeroom Teacher: *

Referred by: *

Homeroom Teacher

Student Request

Parent Request

Other:

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