Thank you for taking the time to complete the referral form. The more information you can provide me regarding your concerns the better I can support you and the student.

Once I receive this form, I will contact parents regarding potential services, resources or referrals to community agencies.

Please keep in mind that:
Parent permission is required for all counseling services.
Not all students referred will receive school based services.

If you have any questions regarding this form or about services offered through the counseling program, please do not hesitate to ask me!