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 ashea@tcsk12.com. If the school counselor is unavailable, please contact the school office at 662-423-9290 or call 911.

Thank you,
Mrs. Shea
2020-2021
Email address *
Date *
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Time *
Time
:
Parent/Guardian's full name? *
What is the student's full name *
What is your relationship to the student? *
Grade Level *
What is their teacher's name? *
Academic Reason for Referral (Check all that apply) *
Required
Social Emotional Reasons for Referral (Check all that apply)
Explanation *
Rate the severity of this issue (impact on learning environment) *
Little Impact
Severe Impact
Concern Level: *
Would you like for the school counselor to contact you before meeting with your student? *
Clear selection
Preferred method of contact: Please include either a phone number or email address *
Comments: Please include any additional information
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