School Counseling Parent Referral Form

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Please fill out this form if you'd like to refer your student to the school counselor, Ms. Kristina. All responses are confidential.

Referring adult: *

Name of student being referred:

Grade: *

Reason for referral: *

Academic

Behavior

Personal

Required

Briefly describe the problem/concern: *

Please provide some helpful information below by marking the behaviors you have observed regarding this student. Your input will be used to assist in developing the best possible support for this student. *

Low grades/achievment

Lack of motivation

Frequently distracted

Incomplete assignments

Cheating

Absent often

Tardy often

Complains of frequent illness

Disruptive

Inattentive/poor concentration

Defiant

Impulsive/hyperactive

Overreacts to situations

Negative attitude

Little/no participation in class

Poor appearance/hygiene

Anger/irritabilty

Withdrawn

Nervous/anxious

Unhappy/depressed

Difficulty making friends

Frequent conflict with friends

Issues at home

Bizarre thinking/behavior

Lying

Other:

Required

Is the student currently participating in counseling outside of school? *

Yes

Not currently, but has in the past

Not currently, but I would like to speak to the counselor about community resources

Any other information you'd like to share:

Submit

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