School Counseling Referral
Referral for school counseling.
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Email *
Person Completing the Referral *
Student: First and Last Name *
Student Grade Level *
Reason for Referral

*** If this is an instance of self-harm, threats or harm to others, or suicidal ideation, please text the counselor immediately or call the school and speak to the principal ***
 *
If other on previous question, please explain
History of referral problem
Any actions taken- parent contacts, conversations with the student, remedies, etc.
Anything else you need the counselor to know
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