Mary Bray Teacher Counseling Referral Form
Please help us get to know how we can support your student.  This information will help us better understand the presented challenges.  This information will be kept confidential.

*Once the form is received, counseling services will begin within two weeks and last approximately 6-8 weeks, contingent on student progress.   

Megan Corcoran, School Counselor, M.ED
mcorcoran@mtephraimschools.com 

 
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Staff Name *
Student's First and Last Name
 *
Todays date *
MM
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DD
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YYYY
Grade *
Parent/Guardian Name and Relationship to Child
Parent/Guardian Email Address, if known
Parent/Guardian Phone Number
Please let us know if there is any household information you would like to share.
 *
Please identify your primary concern(s)- Academic (Check all that apply).
 *
Required
Please identify your primary concern(s)- Personal/Social (Check all that apply).
 *
Required
Describe the student's relationships with classmates/peers.
 *
Describe any difficulties in school (ie. subjects, times of day, locations)
 *
Does this student have a current IEP?   *
Does this student have a current 504 plan? *
Please provide any other information you would to share at this time.
 *
What are some goals you hope to see the student achieve through counseling?
 *
Have you shared your concerns with the student's parents/guardian? *
Have you informed the parents/guardian that you are submitting a counselling referral form? *
Please share the best time of day for the student to meet with the counselor.  *
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