Iuka Elementary School: Parent/Guardian Referral for School Counseling Services
This referral form is for Parents and Guardians of Iuka Elementary School students. The school counselor, April Shea, will contact either you or your child within two school days of receiving this referral. If this referral is urgent or you are concerned for the safety of your student, please contact the school counselor immediately at
. If the school counselor is unavailable, please contact the school office at 662-423-9290 or call 911.
Parent/Guardian's full name?
What is the student's full name
What is your relationship to the student?
What is their teacher's name?
Academic Reason for Referral (Check all that apply)
Social Emotional Reasons for Referral (Check all that apply)
Self Image / Self Esteem / Confidence
Dramatic Change in Behavior
Grief-Loss / Death
Bullying / Target
Bullying / Perpetrator
Self Injury (cutting, biting, head banging, etc...)
Daydreams / Fantacizes
Difficulty in Peer Relationships (social skills / friendships)
Anxiety / Worried / Scared
Uncooperative / Defiant
Impulsive / Hyperactive
Inattentive / Distracted
Withdrawn / Shy
Rate the severity of this issue (impact on learning environment)
Low: minor concern that can wait to be addressed.
Moderate: important concern that needs to be addressed in a few days.
Emergency: a student is at risk to self or others and needs to be seen IMMEDIATELY (possible abuse, neglect, threat of harm to self or others)
Would you like for the school counselor to contact you before meeting with your student? *
Yes, please contact me first
No, but please follow up with me after meeting with my student
Preferred method of contact: Please include either a phone number or email address
Comments: Please include any additional information
Send me a copy of my responses.
Never submit passwords through Google Forms.
This form was created inside of Tishomingo County School District.