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.
Email address *
Email Address *
Your answer
Scholar Name *
Your answer
Grade Level
Referring Staff Member/Parent/Adult
Your answer
Reason for Referral
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.
Time & Place *Include student's HOMEROOM, the time, and classroom from where I can call this student down or retrieve them at your preference
Your answer
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? *
Your answer
Has another adult been notified?
Describe your communication with this adult/agency. (Write N/A if another adult has not been contacted).
Your answer
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