2019 - 2020 Student Self-Referral Form
Please complete this referral form for students who need counseling services. All referrals will be prioritized according to need. If this is an emergency, notify a counselor and/or administrator as soon as possible.
Level of Urgency
Green - "See me whenever."
Yellow - "This is important, but, it can wait a few days."
Red - "This is an emergency, I need to see you ASAP!"
Area of Concern
Academic ("I need help with my grades." "I'm struggling to keep up.")
Social ( "I'm struggling to balance my friendships." "I think I may get into a fight.")
Emotional ("I can't control myself when I'm angry." "I feel sad all of the time." "I can't stop feeling nervous.")
Behavioral ( "I get in trouble a lot." "I like to break rules." "I argue with adults a lot.")
Please explain your issue below:
Send me a copy of my responses.
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This form was created inside of Valdosta City Schools.