Elementary Counselor Referral Form

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Referrals will be sent to the campus counselor by default. In the event that the campus counselor is not able to meet with the student in a timely manner, the next available counselor will follow up on this request.

Email *

Name of staff member referring the student:

Name of student being referred: *

Grade *

5th grade

4th grade

3rd grade

2nd grade

1st grade

Kindergarten

Pre-K

Required

The student needs to talk about... *

schoolwork and assignments

another student

family/home

feelings

choices

friend stuff

Other:

Required

My problem is... *

Urgent (the student needs to be met with today)

Important (the student can meet within 1 or 2 days)

Glitch (the student has talked with a teacher or another adult and needs to meet some time this week.)

Required

Please leave a brief explanation of why you are referring this student and a time during the student's schedule that they can be pulled from class.

Submit

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This form was created inside of Charlotte Independent School District.