School Counselor Referral Form (for parents and teachers)
In crisis or emergency situations at school please accompany student to the office, or call for additional support.
This form does not replace a discipline referral.
Date: *
MM
/
DD
/
YYYY
Student Name: (Last, First) *
Who is making this referral? (Name and relationship to student) *
Reason for referral: *
Please check all that apply.
Required
Urgency: *
Additional Comments:
Submit
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