Parent/Guardian Referral for Counseling
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Legal Guardians Name *
Student First and Last Name? *
Parent Concerns: *
Please mark all of your concerns below: "Trauma Exposed Behaviors"
Please mark all of your concerns below: "Depressive Behaviors"
Please mark all of your concerns below: "Disruptive Behaviors"
Please mark all of your concerns below: "Other"
Has your child had counseling services before? *
I understand that a member from the student support team will contact me before any services begin. *
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