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PARENT School Counseling Referral Form
Please complete this referral and submit. If you have an emergency, please notify Mrs. Pike or Mrs. Jenkins immediately by phone at 270-422-7550.
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* Indicates required question
Email
*
Your email
Student's Name
*
Your answer
Grade
*
K
1
2
3
4
5
6
Student's Teacher
*
Your answer
REFER TO:
*
aimee.pike@meade.kyschools.us
Person making referral, relationship to student and contact information such as email address and/or telephone number.
*
Your answer
What does the student need see the school counselor about?
*
Friendships
Family
School Work
Him/Herself
Other
Is there any other information you want to share that could be helpful to this situation?
*
Your answer
When does the student need to see the counselor?
*
Sometime soon (within 2 or 3 days)
As soon as possible (by the end of the day)
How do you prefer to get follow up from the school counselor.
*
Telephone Call (please include your telephone number in section four above)
E-mail (please include your e-mail in section four above)
I only need to be contacted for follow up if the school counselor feels it is necessary.
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