Lugonia Counseling Request Form 25-26

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This referral will be reviewed by the counseling team to determine if one of the following counseling tier 2/Tier 3 supports is appropriate:

If counseling referrals seem to need behavior support, they will be referred to the PBIS team for further evaluation.

First and Last Name of person submitting referral *

Teacher's Name *

Student's First Name *

Student's Last Name *

Grade *

Referred by *

Staff

Admin

Parent/Guardian

Student request

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This form was created inside of Redlands Unified School District.