ECC & ES Parent/Guardian Referral Form for School Counselor
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Student's Name
Grade and Teacher 
Your name and relationship to student
Phone number 
Best times to reach  you 
My child's strengths include: 
My primary concern(s) (Check all that apply) 
Additional Information regarding concern(s) 
My child needs to be seen 
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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. 
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