Counseling Referral Form(Parent/Guardian)
Thank you for completing this form with as much detail as possible. The school counselor will evaluate each referral and determine if your child qualifies for counseling services at Cristo Rey Tampa Salesian High School. If your child is experiencing a mental health crisis, is a risk to themselves or others, or in need of immediate assistance please call 911 or contact the Crisis Center of Tampa Bay(211).
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Name of Parent *
Parent/Guardian Contact Information *
Name of Child *
Child Grade Level *
Area of Concern *
Has your child ever been diagnosed with a mental health illness? If so, please list their diagnosis and any medications that they are currently taking. *
Please describe the mental health concerns that you have regarding your child and when they began. *
What changes would you like to see in your child?
Has your child ever participated in counseling/therapy before? *
Is your child aware that you are making this referral? *
Would you and/or any other family members be willing to participate in family counseling, if needed? *
Please include any other relevant information you feel will be helpful for the counselor.
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