School Counseling Referral Form 
Referrals for students to see the counselor 
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Student Name  *
Date *
MM
/
DD
/
YYYY
Student's Homeroom Teacher *
Grade Level  *
Who is making the referral? *
Required
What is the challenge the student is facing?  *
Required
When should the student be seen? *
Please add any additional details about your concern that may be helpful (ex. parent contacts, parent responses, intervention used, etc.)
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This form was created inside of Cabarrus County Schools.