School Counseling Referral Form
The purpose of this form is to document your referral. Please be sure to enter information appropriately and as completely as possible. Mrs. Farris will be notified by email when your request is submitted.
Referring Staff Member/Parent/Adult
Reason for Referral
Dramatic Change in Behavior
Negative Attention Seeking
New Student Adjustment
Peer Relationships/Social Conflict
Second Harvest Food Referral
SUDS 4 STUDENTS Referral (UPPER SCHOOL ONLY)
HealthConnect Therapy Referral
CCFT (Intensive In-Home Services for Families)
Other (Please explain in section below)
Urgency of Need ** An emergency with immediate need means that the student is in crisis, in danger of harm to self or fearing for his/her safety. Choosing "today" means that you have concern that they should see me before leaving the school.
Immediately, as soon as possible (If choosing this, please text me at 865-456-1463)
Sometime this week
Time & Place *Include student's HOMEROOM, the time, and classroom from where I can call this student down or retrieve them at your preference
Brief Description *What behaviors are being demonstrated/language used by scholar? What strategies have you employed? Any other context or helpful information for the counselor?
Has another adult been notified?
Police, Child & Family Services, other agency
Describe your communication with this adult/agency. (Write N/A if another adult has not been contacted).
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