Electronic School Counselor Referral Form (Parent/Guardian Form) 2023-2024
This school counselor referral form was created by the ESS department in the Kyrene School District.  

This form does not guarantee that your child will immediately begin receiving school counseling services. However, after your school counselor receives this form you will be contacted for further discussion of your child. Thank you 😊
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Email *
Please include a phone number that you can be contacted at: *
Your name: *
Please select the option that applies to you: *
If you selected "other" please describe here:
Today's Date: *
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School Name: *
Student's Full Name: *
Grade: *
Teacher Name *
Reason for school counseling referral: (Please check all that apply and use the "comments" space for further details):                                                     *
Required
Comments: *
Interventions tried (Before school counselor referral): *
What other services is the student receiving (tutoring, out of school counseling, etc)? *
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This form was created inside of Kyrene School District.