Referral to Ms. Marie
To make a referral or request an appointment with the counselor, please fill out the information below. If this is an emergency (suicidal thoughts or actions, fear of harm by self/others, etc.) please go to the counselor or other trusted adult immediately. If this is an emergency outside of school hours, call 911.
A Student Referring Myself
A Student Referring Someone Else
A Teacher/Staff Member
Student's Last Name
Student's First Name
Name of Referring Person (if not self)
Best time to contact or make an appointment?
Low: Schedule when available
Medium: Sooner rather than later
High: As soon as possible
Reason for appointment
Please check all that apply
Grades and School Work
Teacher/Other Adult Concerns
Please explain if you can:
"I'm struggling with homework," "fight with friend," scholarship questions," etc.
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This form was created inside of Charlo School District 7J.