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ECC & ES Parent/Guardian Referral Form for School Counselor
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Student's Name
Your answer
Grade and Teacher
Your answer
Your name and relationship to student
Your answer
Phone number
Your answer
Best times to reach you
Your answer
My child's strengths include:
Your answer
My primary concern(s) (Check all that apply)
Something's wrong but I don't know what
A loss (e.g. death of a person or pet, loss of a friendship, parents' divorce)
Anger
Perfectionism
Relationships with friends/peers
Relationships with brothers/sisters
How my child is treated by others
Feelings of negativity, discouragement, self-doubt
Unhealthy or unsafe choices
Study skills, grades and schoolwork
Other concern(s)
Additional Information regarding concern(s)
Your answer
My child needs to be seen
URGENT- TODAY!
As soon as possible
After the counselor and I talk
Clear selection
CONFIDENTIALITY AGREEMENT: (excerpt taken from www.schoolcounselor.org)
The counseling relationship between students and their school counselor requires an atmosphere of trust and confidence. Students must trust the school counselor to be able to enter into a meaningful and honest dialogue with the school counselor. However, students should be informed that exceptions to confidentiality exist in which school counselors must inform others of information they obtained in the counseling relationship to prevent serious and foreseeable harm to students themselves or others and if it is legally required.
**Please mark below that you have read and agree to the Confidentiality Agreement.
*
Yes, I agree to the Confidentiality Agreement
No, I don't agree to the Confidentiality Agreement.
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