Confidential Referral for School Counseling Support

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To make a referral or request an appointment with Mr. Starck, please fill out the information below.

If this is an emergency (i.e. safety concern, fear of harm by self/others, suicidal thoughts/actions, etc.) please go to the counselor or other trusted adult immediately. If this is an emergency outside of school hours, call 911 or 988 (suicide & crisis lifeline).

I am *

A teacher/staff member

A parent/guardian

A student, referring myself

A student, referring someone else

Other:

Student's First Name *

Student's Last Name *

Priority *

Low (schedule when available)

Medium (increasing level of concern)

High (as soon as possible)

Name of referring person *

Does the student know you are making a referral? *

Yes

Best method to talk further? *

In person

Phone

Google Meet/Zoom

Contact Email/Phone Number *

Reason for appointment? (check all that apply) *

Grades/Schoolwork

Family/Home Concerns

Friendship/Social Concerns

Concern with Adult(s) in Student's Life

Grief/Loss

Aggressive Behavior

Relationships and/or Sexuality

Frequent Physical Complaints

Stress/Anxiety

Motivation

Self Harm and/or Suicidal Ideation

Absenteeism/Tardy (chronic)

Other:

Required

Please briefly explain:

Submit

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