WCCS - Counseling Referral Form 2017-2018
Use this form to refer a student to a school counselor. If the referral is in any way related to self harm, suicide or any type of abuse, speak to a counselor or an administrator in person immediately.
Student Name (Last, First) *
Your answer
Name of Person Completing Referral (Last, First) *
Your answer
Student Grade Level
Which Counselor is this Referral for?
Academic Concerns
Social Concerns
Attendance Concerns
Situational Concerns
Briefly describe your concerns in the space below.
Your answer
The level of your concern is
Remember: If the referral is in any way related to self harm, suicide or any type of abuse, speak to a counselor or administrator in person immediately.
Your answer
Thank you for completing this form. A copy of your responses will be emailed to the counseling team and they will follow up with you as soon as possible.
Your answer
Submit
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