Counseling Services Referral
Confidential referral for student counseling services
Email address *
Date *
MM
/
DD
/
YYYY
Student Name *
Your answer
Grade *
Your answer
Referred by *
Required
Referring issue(s) *
Your answer
Self Concept and Emotional Regulation *
Strongly Disagree
Disagree
Agree
Strongly Agree
N/A
Knows and appreciates the good things about him/herself and the things he/she can do well
Has the skills to manage his/her feelings in a positive way (self-regulation)
Has the skills to speak up for him/herself and the courage to try
Can think positively even if things are difficult or hard
Has stress management skills that support student in stressful situations
Likes how he/she thinks, feels, and acts
Anger Management *
Strongly Disagree
Disagree
Agree
Strongly Agree
N/A
Is able to use self control, is able to stay in control with what he/she does and says even though he/she is angry
Handles disagreements/conflicts with his/her friends without intervention from adults
Handles it well when staff corrects his/her behavior
Has strategies he/she uses when angry
School Success *
Strongly Disagree
Disagree
Agree
Strongly Agree
N/A
Behaves well in class
Stays focused and listens carefully in class
Is organized
Has a good attitude about the school
Complete his/her work efficiently
Friendship/Social Skils *
Strongly Disagree
Disagree
Agree
Strongly Agree
N/A
Is able to make friends and keep friends
Is good at listening to others (not just their words but their feelings too)
Is able to get along with others by sharing, taking turns and being flexible
Can use problem solving skills tomanage conflict and keep things calm
Plays fairly and by the rules
Is a good sport in games and can handle the frustration of losing
Please pick two or three target goals from above that you would like us to focus on during our counseling time. *
Your answer
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